Kidney Disease Form

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Camper Name:_______________________________________
Birthdate:______________________________________
KIDNEY DISEASE FORM
TO BE COMPLETED BY A LICENSED HEALTH CARE PROVIDER
This form, in addition to the Physical Exam form, must be completed by the medical
Specialty MD:__________________________________ Day Phone:________________ After Hours Phone:_________________
Address:_____________________________________________________Email:________________________________________
Hospital:_______________________________________________ Nurse Coordinator:__________________________________
Diagnosis:________________________________________________________________________________Date of Diagnosis:_______________
Secondary Diagnoses:_____________________________________________________________________________________________________
Current Treatment:________________________________________________________________________________________________________
Categories/Complications:
Kidney Transplant?
□ YES
□ NO
If YES, Date of transplant:___________________________ # of transplants:_________
Kidney Wasting Syndrome?
□ YES
□ NO
If YES,
□ Water Only
□ Electrolytes and water
Chronic Kidney Disease?
□ YES
□ NO
If YES, what stage CKD:
□ Stage 1-2
□ Stage 3
□ Stage 4
□ Stage 5 (ESRD)
Please provide BP parameters:
Call for BP greater than____________ OR Less than____________
Most recent creatinine:_______
Nephrotic Syndrome?
□ YES
□ NO
If YES, is it in remission?
□ YES
□ NO
History of Relapses?
□ YES
□ NO
If YES, # of relapses:_____
Currently in relapse? □ YES
□ NO
Date of relapse: _______________
Hypertension?
□ YES
□ NO
If YES, baseline BP:_____________
Anemia?
□ YES
□ NO
If YES, most recent Hgb_______Hct__________
Diabetes?
□ YES
□ NO
If YES, what is the cause? __________________________
If YES, what type of diabetes?
□ Type 1
□ Type 2
(If insulin is required, please attach most recent insulin regimen)
For Type 2 Diabetes- please indicate diet recommendations for this camper:
No Added Sugar (limit juice to 4oz, no Gatorade)
Low Sugar (no juice, no Gatorade, special snack)
Sugar Free (Crystal Lite, sugar free snacks)
Carb counts required
History of Infection with:
MRSA
VRE
C Diff
If YES, has this infection been cleared? □ YES
□ NO
If NO, is child colonized but asymptomatic? □ YES
□ NO
If NO, details:______________________________________________________
Devices:
Dialysis?
□ YES
□ NO
If YES, indicate type:
□ Hemodialysis (Family camp ONLY)
Date started:_______________
□ Peritoneal Dialysis
Date started:______________________ (Please attach Master Dialysis Form)
Does the child receive tube feedings or require a central line?
□ YES
□ NO
If YES, please complete the Infusion Pump form
Does the child regularly receive lab work?
□ YES
□ NO
If YES, please provide a recent copy
Labs while at camp? □ YES □ NO
If YES, please list lab(s) and date needed: ______________________________________________________
Please attach most recent clinic note
Physician Name (Print):__________________________ Signature:______________________________ Date:________________
Completed By (Print):____________________________ Signature:_____________________________ Date:________________
Fax completed form to 888-524-2477 or email to
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