If your client has a kidney transplant, please answer the following :


      Agent Name:  



   Client Name: 



   Phone:  



   Fax: 
   


   1.  Date of transplant ? 


   2.  Cause of the end stage renal disease which led to the transplant :
       Diabetes
       Glomerulonephritis
       Polycystic Kidney Disease
       Nephrosclerosis
       Systemic Lupus Erythmatosis


   3.  What was the source of the donor kidney :
       Cadaver
       Living Related Donor
       Identical Twin


   4.  Is your client on any medication ? Yes   No 

       If yes, give details: 


   5.  Results of kidney function tests :
       BUN              
       Serum Creatinine 
       Urinalysis       


   6.  Have any of the following ocurred : (please check all that apply)
       Frequent Infection
       Rejection Episodes
       High Blood Pressure
       Cardiovascular Disease
       Toxicity From Treatment
       Cancer
       Disease Recurrence


   7.  Has your client smoked cigarettes in the last 12 months ? Yes   No 


   8.  Does your client have any major health problems ? Yes   No 

       (example: cancer, etc.)

       If yes, give details: