Nephrology Intake Form

The Nephrology Intake Form is tailored for nephrology practices, capturing the detailed renal history that nephrologists need for comprehensive kidney disease evaluation and management. This template collects patient demographics alongside a thorough renal symptom assessment covering edema (location and severity), changes in urine output and color, foamy urine, hematuria, flank pain, fatigue, pruritus, and appetite changes. The CKD staging section captures prior GFR values, creatinine trends, proteinuria quantification, and kidney biopsy history to establish disease trajectory.

Designed for general nephrology, dialysis, kidney transplant, and hypertension practices, this form includes sections for causes of kidney disease (diabetes, hypertension, glomerulonephritis, polycystic kidney disease, obstruction), dialysis history (modality, access type, vintage, adequacy measures, complications), transplant evaluation status, electrolyte and metabolic bone disease management (calcium, phosphorus, PTH, vitamin D), fluid and dietary restrictions, and a comprehensive renal medication list covering antihypertensives, ESAs, phosphate binders, potassium binders, immunosuppressants, and diuretics. The vascular access section documents access type, location, and any prior access complications.

All fields are HIPAA-compliant and structured for the nephrology workflow from initial CKD evaluation through dialysis management. The pre-visit documentation allows the nephrologist to review kidney function trends, medication dosing, and dialysis parameters before the consultation. For new patients transferring from other dialysis facilities, the comprehensive format captures the critical care details needed for seamless transitions.