Sabah Kidney Society

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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 _______________________

       ____________________________________ RM _______________________

       ____________________________________ RM _______________________

       ____________________________________ 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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