CHAPTER 13: Recipient Evaluation Form

We detail a sample Recipient Evaluation Form. We also describe baseline information for patients and a summary of possible captions based on possible candidate characteristics. All these baseline narratives should be adapted to the specific working practices of each individual program.

Patient Name:

I personally saw and examined this patient. My history and physical is based on my own examination and interaction with the patient and those present, on available medical records, as well as on the reports and observations of other members of the team.

Physician requesting consultation:

Nephrologist:

Name, Address and Telephone:

Primary care physician:

Name, Address and Telephone

Others present:

• Cause of kidney failure:

• Previous kidney transplant:  □ Yes  □ No

  Date of diagnosis of kidney failure:

  Date of start of dialysis (hemo/peritoneal):

  Date of diagnosis of hypertension (if any):

  Diabetes:  □ Yes  □ No

  Date of diagnosis of diabetes:

  Insulin Use  □ Yes  □ No

  Date of start of insulin use:

  Retinopathy  □ Yes  □ No

  Neuropathy  □ Yes  □ No

  Lower extremity ulcers  □ Yes  □ No

  Routine foot evaluations  □ Yes  □ No

  Cardiac history:  □ Yes  □ No

  Maximum distance able to walk non-stop:  □ blocks

  Claudication / Angina:  □ Yes  □ No

  History of DVT/thrombosis/miscarriage:  □ Yes  □ No

  Blood transfusions:  □ Yes  □ No

  Course complicated by:

• Allergies:

  □ No

  □ Yes

• History of chronic pain:  □ Yes  □ No

  Current Medications:

  Family History:

  Father: Age  □ Deceased  □ Alive  Cause of illnesses/death:

  Mother: Age  □ Deceased  □ Alive  Cause of illnesses/death:

  Family history of kidney disease:  □ Yes  □ No

  Other:  □ Yes  □ No

  Social History:

  Occupation

  Marital Status:  □ Single  □ Married  □ Divorced  □ Separated  □ Widowed  □ Other

  Children  □ Yes  □ No

  Potential live donors:  □ Yes  □ No  □ Unknown

  Habits

  Smoking  □ Yes  □ No

  Drinking  □ Yes  □ No

  Studies reviewed:

  □ None available to me at the present time

  □ Yes

REVIEW OF SYSTEMS:

General:

Difficulty sleeping  □ Yes  □ No

Fatigue  □ Yes  □ No

Fevers or chills  □ Yes  □ No

Night sweats  □ Yes  □ No

Weight changes  □ Yes  □ No Amount:

Head, ears, nose, and throat:

Hearing loss  □ Yes  □ No

Lesions removed  □ Yes  □ No

Loss of smell  □ Yes  □ No

Loss of taste  □ Yes  □ No

Tinnitus  □ Yes  □ No