Kidney/Self-care

Sabah Kidney Society

Kidney Failure | Treatment | How to get help | Sponsoring Home Page

Conditions | Agreement

Self-care Haemodialysis

Application Form

(Fill then print a copy of the form and send the form to the society through fax: 088-211664 or to Sabah Kidney Society at No. 822, Taman Dah Yeh Villa, Jalan Damai, 88400,
Kota Kinabalu Sabah, Malaysia Tel:088-219901)

(Please submit a copy of your passport size photograph)

PART A: SOCIAL REPORT (TO BE COMPLETED BY APPLICANT)

1. Personal Information

Name : _______________________________________

NRIC No: __________________________________

Sex:___________(Male/Female)

Address: ______________________________

_______________________________

_______________________________

________________________________

Telephone: __________________________(O) ______________________(H)

Relative (specify): _______________________________________________

Date of Birth: _____________________ Place of Birth: ____________________

Nationality: _____________________________________________________

Marital Status: Single/Married/Divorced/Others ________________________

2. Details of Employment:

Employed/Not Employed PresentEmployment: __________________________

Employer's Name: ________________________________________________

Address: ____________________________________

____________________________________

____________________________________

Telephone No: ______________________

Monthly Income: RM _____________________per month

3. Educational Background.

School - Primary: Completed/Not completed
- Secondary: Completed/Not completed

College/University: ______________________________________________

Others: _______________________________________________________

4. Details of Financial Status

(A) Name of Property/Assets Owned

Property Value

1. ____________________________ RM __________________

2. ____________________________ RM __________________

3. ____________________________ RM __________________

(B) Sources of Income

1. ____________________________ RM __________________

2. ____________________________ RM __________________

3. ____________________________ RM __________________

5. Family Information.

Name Relationship Sex Age Occupation Monthly Income

_____________________________________________________________________

_________________Spouse: _____________________________________________

_________________Father: ______________________________________________

_________________Mother: _____________________________________________

_________________Brothers/Sisters: ______________________________________

_________________ ______________________________________

Give name and address of next of kin, in caseof emergency:

Name: _____________________________ Relationship: _________________________

Address: _______________________________________________________________

___________________________ Telephone (O) ___________(H) _________

6. Children Particulars:

Name Age Sex Occupation Education Monthly
Level Income

_______________________________________________________________

7. Family's total monthly income and expenditure:

Total Income: RM _______________________

Less Expenditure:

____________________________________ RM _______________________

Balance: RM _______________________

8. Type of Accommodation:

Own House/Provided by Employer
Rented House: RM _____________________ per month

Type of House: Attap Shop Terrace Semi-Detached Bungalow Others
_________

9. Other Information:

a) How long have you suffered from kidney failure ?
_____________________________________

b) What other medical conditions do you suffer from ?
____________________________________________________________

c) Who is your regular doctor ?
____________________________________________________________

d) Who is your specialist ?
____________________________________________________________

e) What's drug are you on ?
___________________________________________________________

f) Are you waiting for :-

Home Haemodialysis ___________________________________________

Transplanation _______________________________________________

C A P D ____________________________________________________

Are you presently on dialysis elsewhere ? (YES/NO)

If so, please state:

Where: ____________________________ Since when: _______________

How often: ____________________ Fees paid per session: RM _________

10. Declaration:

I declare that:-

a) All the particulars given on this form are true and I have not withheld any information required;

b) I am prepared to allow Sabah Kidney Society to publicize my connection with self care haemodialysis programme, if necessary;

c) If I am selected for the programme, I will be subjected to a review every 6 months;

d) I may be terminated from the programme if I do not meet the contents of the contract between the Sabah Kidney Society and myself;

e) If I have withheld any information the Sabah Kidney Society reserves the right to terminate my participation in the programme; and

f) I will undertake to provide an assistant to be trained simultaneously with me.

Date: ____________________ Applicant's Signature: ______________________

PART B: MEDICAL REPORT (TO BE COMPLETED BY A MEDICAL DOCTOR)

1. Detail of Sickness:
(Including primary causes, complications & concurrent diseases)

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

2. Indications for Haemodialysis:

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

3. Current Medications and Dosage:

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

4. Precaution/Contraindication for Haemodialysis:

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

5. Does the patient have:

Yes No Specify

HBSAG ___________ ______________ _______________

HbSAb ___________ ______________ _______________

HIVAb ___________ ______________ _______________

HCAb ___________ ______________ _______________

6. Any plan for transplantation ? (Yes/No)

7. Is patient fit to continue employment after dialysis ? (Yes/No)

8. Access: Tick

1. A-V Fistula _______________

2. A-V Shunt _______________

3. None _______________

9. Current method of treatment:

1. Conservative treatment ________________________________________

2. Pertoneal Dialysis ________________________________________

3. Haemodialysis ________________________________________

Date of first dialysis _______________________________________

Place of current dialysis _______________________________________

Frequency of dialysis _______________________________________

10. Prognosis: __________________________________________________

____________________________________________________________

____________________________________________________________

11. Follow up instruction:

___________________________________________________________

__________________________________________________________

12. Note for doctor referring patient:

        I have examined the above patient and found that he/she is fit/unfit for self care
        Haemodialysis Programme in Sabah Kidney Society (if selected). I understand that
        his medical management will be outside the ambit of Sabah Kidney Society and
        that I shall arrange for this patient to be managed medically by such qualified person(s)
        that I deem fit.

Signed: ____________________________

Name of Doctor: ________________________________________

Address: ______________________________________________

______________________________________________

Date: _____________________

PART C: REMARK (TO BE COMPLETED BY INVESTIGATING OFFICER)

Date: _________________________ Chairman, Welfare Subcommittee

PART D: SELECTION COMMITTEE DECISION

Approved/Not Approved

RM __________________________ per session w.e.f ____________________

Date: _________________________ Chairman, Selection Subcommittee

REF:ADMFORM2.SKS

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Self-care Haemodialysis

Application Form

(Fill then print a copy of the form and send the form to the society through fax: 088-211664 or to Sabah Kidney Society at No. 822, Taman Dah Yeh Villa, Jalan Damai, 88400, Kota Kinabalu Sabah, Malaysia Tel:088-219901)

(Fill then print a copy of the form and send the form to the society through fax: 088-211664 or to Sabah Kidney Society at No. 822, Taman Dah Yeh Villa, Jalan Damai, 88400,
Kota Kinabalu Sabah, Malaysia Tel:088-219901)