RENAL REPORT




Patient Name: _______________________________________

Social Security #: ____________________________________

Date of Birth: ________________________________________

TO THE DOCTOR: Please complete the following report attaching copies of lab results for each condition. Please use the back of the form if additional space is needed.

1. Does this patient suffer from any liver impairment or disease?    ____YES  ____NO.  
If yes,

A. What is the current diagnosis? ___________________________________________
____________________________________________________________________
B. On what date was the diagnosis first made? _________________________________
C. What is the date of onset, if different? ______________________________________
D. How long have you been treating the condition? ______________________________
E. What is the date of the most recent examination? _____________________________
F. What was the patient's height_____ weight ____ at that time?

NOTE: IF THE DIAGNOSIS IS CARCINOMA, alternate forms will be provided. Do not complete this form unless there is an independant renal impairment.

2. Does the patient suffer from:
      A. Acute renal failure? Yes_____ No_____ If so:
            1. Date first diagnosed____________________
            2. etiology_______________________________________
            3. aggravating or complicating factors______________________________________
                 ________________________________________________________________
      B. Chronic renal failure? Yes_____ No_____
      C. Nephrotic Syndrome or nephritis Yes_____ No_____
      Type? _____________________________________________________________
      D. Hypertensive vascular disease Yes_____ No_____
      If so, what clinical signs have you observed?
      __________________________________________________________________
      E. Renal osteodystrophy? Yes_____ No_____
      If so, is there
            1. severe bone pain Yes_____ No_____
            2. radiographic abnormalities such as
                  osteitis fibrosis Yes_____ No_____
                  marked osteoporosis Yes_____ No_____
                  pathological frac Yes_____ No_____
            Please attach copies of x-ray reports to this form.
      F. Pericarditis Yes_____ No_____
      G. Persistent motor or sensory neuropathy Yes_____ No_____
      H. Persistent fluid overload syndrome Yes_____ No_____ with
            1. diastolic hypertension Yes_____ No_____
            2. signs of vascular hypertension Yes_____ No_____
      I. Necrotic syndrome Yes_____ No_____ with
            anasarca Yes_____ No_____

3. Have any of the following tests been performed?
  Yes No Date Results
a. protein in urine ____ ____ __________ _____________
b. glucose in urine ____ ____ __________ _____________
c. ketones in urine ____ ____ __________ _____________
d. blood in urine ____ ____ __________ _____________
e. nitrite ____ ____ __________ _____________
f. Ph ____ ____ __________ _____________
g. serum creatinine ____ ____ __________ _____________
h. Bun/creatinine ratio ____ ____ __________ _____________
i. CO2 ____ ____ __________ _____________

4. Have you observed
      A. Edema? Yes_____ No_____ If so,
      dates ______________________________________
  Yes No
pretibial ______ ______
periorbital ______ ______
presacral ______ ______
      B. Ascites? Yes______ No______

5. Has the patient reported or have you observed any of the following symptoms consistent with the diagnosis?
  Yes No Date
A. vomiting ____ ____ __________
B. fever ____ ____ __________
C. nausea ____ ____ __________
D. weight loss ____ ____ __________
E. dyspnea ____ ____ __________
F. malaise ____ ____ __________
G. weakness ____ ____ __________
H. dysuria ____ ____ __________
I. nocturia ____ ____ __________
J. polyuria ____ ____ __________
K. oliguria ____ ____ __________
L. anuria ____ ____ __________
M. hematuria ____ ____ __________
N. peripheral neuropathy ____ ____ __________
O. percarditiss ____ ____ __________
P. pallor ____ ____ __________
Q. skin lesions ____ ____ __________
R. enlarged kidney ____ ____ __________
S. enlarged bladder ____ ____ __________
T. decreased mental acuity ____ ____ __________
U. cramps ____ ____ __________
V. convulsions ____ ____ __________
W. pruritis ____ ____ __________
X. pleural effusion ____ ____ __________
Y. pericardial effusion ____ ____ __________
Z. hydroarthrosis ____ ____ __________
AA. orthostatic hypotension ____ ____ __________
BB. recurrent infection ____ ____ __________
CC. venous thrombosis ____ ____ __________

6. What diagnostic procedures have been performed
  Yes No Date Results
radiograph ____ ____ __________ _____________
excretory urograph (IVP) ____ ____ __________ _____________
retrograde pyelogram ____ ____ __________ _____________
CT scan ____ ____ __________ _____________
ultrasound ____ ____ __________ _____________
biopsy ____ ____ __________ _____________
other ____ ____ __________ _____________
describe______________________________________________

7. What therapeutic procedures have been prescribed or performed?
A. Dialysis Yes_____ No_____ If so,
type________________________________________________
for how long__________________________________________
how long to continue____________________________________
complications_________________________________________
B. Transplant Yes_____ No_____ If so,
when________________________________________________
why_________________________________________________
where performed_______________________________________

8. What is the present therapy for the condition_____________________________
_________________________________________________________________
_________________________________________________________________
9. What is the present therapy for the condition_____________________________
_________________________________________________________________
10. What drugs have been prescribed____________________________________
_________________________________________________________________
_________________________________________________________________
11. Are there any side effects from the medication observed or reported? Yes_____ No_____
If so, what?________________________________________________________
_________________________________________________________________
12. What modifications to life style or daily living have been recommended
_________________________________________________________________
_________________________________________________________________
13. From what other medical or psychological condition does patient suffer in addition to those described above ________________________________________________________
_____________________________________________________________________
14. Are you treating those conditions? Yes_____ No_____


Date Report Completed: ______________________________
Signature of Physician: ______________________________
Physician Name: ______________________________
Address: ______________________________
Telephone: ______________________________
Specialty: ______________________________

Law Office Of:
Jerrold S. Zivic
850 W. Jackson Blvd.
Suite 405
Chicago, IL 60607
800-400-4357

RENAL REPORT
Bureau of Disability Determination Services Applicant: ___________________________
Post Office Box 19250 Social Security #: ______________________
Springfield, IL 62794-9250 Adjudicator: _________________________

NOTICE TO PHYSICIAN: Medical information is needed to establish your patient's eligibility under the disability provisions of the Social Security Act. Please refer to references. This form is for your convenience; however, if you prefer, it is acceptable to submit your report on your own letterhead with photocopies of hospital summaries or other reports attached.

1. Date of most recent exam: ___________ Height:________ Weight: _________

2. Current Diagnosis: _____________________________________________________

3. Clinical findings - Please describe fully and indicate persistence of symptoms

Blood pressure (repeated over at least 3 months)

BP:________ Date:________;BP:________ Date:________; BP:________ Date:________;

Laboratory results (repeated over at least 3 months)
Serum Creatinine Date Creatinine Clearance Date BUN Date
_____________ ________ _____________ ________ _____ ________
_____________ ________ _____________ ________ _____ ________
_____________ ________ _____________ ________ _____ ________
Hemocratocrit Date Serum Albumin Date Proteinuria Date
_____________ ________ _____________ ________ _____ ________
_____________ ________ _____________ ________ _____ ________
_____________ ________ _____________ ________ _____ ________

5. Xrays - pyelogram findings (give dates)_______________________________

6. Type of surgery performed: _________________________ Date: ___________

7. Pathology report: Date:__________ Finding: ___________________________

8. Treatment and Response:________________________________________________

      Is this individual receiving renal dialysis?______________________________
      If so, how often and when?_________________________________________________

9. Please describe any other impairments or conditions not covered by the questions on this form:

______________________________________________________________________

10. Please describe the patient's ability to do work-related activities such as sitting, standing, moving about, lifting, carrying, handling objects, hearing, speaking, traveling: (use reverse if necessary)

______________________________________________________________________

______________________________________________________________________

This state agency is requesting disclosure of information that is necessary to accomplish the statutory purpose as outlined under 20CFR404.1601 et. seq. Disclosure of this information is VOLUNTARY. This form has been approved by the State Forms Management Center.

______________________________________________________________________
(Physician's Signature and Title)            (Date)           (Telephone Number)

______________________________________________________________________
(Street Address)           (City)          (State)           (Zip Code)
DF:526            IL:488-0410