FORM DATA PASIEN HEMODIALISA BEPERGIAN

TRAVELING DIALYSIS INFORMATION FORM

DATA PASIEN / PATIENT INFORMATION :

Nama Pasien /Patient name : Jenis Kelamin/Gender :

Tanggal Lahir/Date of birth : Umur/Age :

Alamat /Address : Kewarganegaraan/Nationality :

Telepon / Mobile Phone :

DATA MEDIS PASIEN / MEDICAL PATIENT INFORMATION :

Allergy :

Blood type :

First dialysis :

Last dialysis :

Target dry body weight :

Recent body weight :

Type of Dialyzer :

Access Vascular :

Dialyzer flow rate :

Blood flow rate :

Ultrafiltration Goal :

Heparin Used :

Problem during hemodialisa :

Bandar Lampung,