Personal Information
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First Name : |
___________________ |
Middle Name : |
___________________ |
Last Name : |
___________________ |
Address : |
___________________ |
Phone Number : |
___________________ |
Cellular/Pager Number : |
___________________ |
Email Address : |
___________________ |
Occupation : |
___________________ |
Birth Date : |
___________________ |
Gender : |
___________________ |
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Medical Information
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Doctor's Name : |
___________________ |
Doctor's Address : |
___________________ |
Kidney Center : |
___________________ |
Product Specialist : |
___________________ |
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Treatment Information
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Type of Dialysis(check one) : |
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| ______ |
Pre Dialysis |
| ______ |
Hemodialysis |
| ______ |
Peritonial Dialysis |
| ______ |
Others
Please Specify: _______________ |
Number of months or
years in dialysis : |
______ |
Number of months or
years on Eprex : |
______ |
I take : |
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| ______ |
Eprex |
| ______ |
Recormon |
| ______ |
Others
Please Specify: _______________ |
Eprex Dosage : |
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| ______ |
2000 1 x a week |
| ______ |
2000 2 x a week |
| ______ |
4000 1 x a week |
| ______ |
4000 2 x a week |
| ______ |
4000 3 x a week |
| ______ |
Others
Please Specify: _______________ |
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