Kidney and Hypertension Consultants

Patient's Name

Date

List Surgeries and Serious Illnesses with Dates

HEART

ENDOCRINE

LUNG

NEUROLOGY

URINARY

BLOOD

(If yes, type)

G.I. TRACT

FAMILY HISTORY

Add Additional Name

If yes, Please Select

If yes, How Much?

How Many Years

If yes, How Much? and Often?

Is there any kidney disease or blood pressure problems in the family, if so, please indicate which relative

Number of pregnancies or miscarriages?

Were there any blood pressure problems during pregnancy?

List ALL Medications which you are taking PLEASE INCLUDE MG AND TIMES TAKEN

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Date

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