Service de dialyse
DEPARTEMENT DE MEDECINE INTERNE
SERVICE DE NEPHROLOGIE
Dr Pierre DUHOUX – Dr Dominique POUTHIER – Dr Fernand PROSPERT
Contact numbers
Secretary Tel: (+352) 4411-2022 Hospitalisation Tel: (+352) 4411-2736
Dialysis Tel: (+352) 4411-2324 Fax: (+352) 4411-6056 Limited Care Tel : (+352) 4411-2373
Name, Address and Social Security details
Contact Details for Dialysis Centre
Contact
Details
for
Holiday
Residence
Address_____________________________
Address__________________________
____________________________________
_________________________________
____________________________________
_________________________________
Telephone ___________________________
Telephone_________________________
Fax _________________________________
Fax______________________________
E-Mail_______________________________
Email_____________________________
Emergency Contact
___________________________________________________________
___________________________________________________________________________
Dialysis Schedule
Dates
Times (from/to)
Medical Summary (to be completed by treating physician)
1. Reason for Renal Failure _______________________________
______________________________________________________
______________________________________________________
2. Medical History ______________________________________
______________________________________________________
______________________________________________________
3. Surgical History ______________________________________
______________________________________________________
______________________________________________________
______________________________________________________
4. Allergies ___________________________________________
5. Medical Treatment required during treatment
6. Medical Treatment at home
Dialysis Observations
1. Dialysis
Blood Pressure Pre-Dialysis
Blood Pressure Post Dialysis
Dry Weight
Weight gain between sessions
Blood Flow
Dialysate Flow
UF Profile
Na Profile
Anticoagulation
2. Dialysate
HCO3Na+
K+
Ca++
Glucose
Dialysis Access
1. Vascular Access via AV Fístula:

Right / Left

Localisation

Single Access : Needle / Catheter

Double Access :
Veina – Needle/Catheter
Arteria – Needle/Catheter
2. Hickman Catheter :

Localisation

Right / Left

Single Lumen / Double Lumen

Heparin dose for each lumen
o – Single
_______ ml
o – Double : Veina
_______ ml
Arteria
Haemodialysis Machine
TYPE
_______________
SURFACE
_______________
MEMBRANE

FX80

FX100

F8

TCA 150

TCA210

OTHER ____________________
_______ ml
Additional Information

Serology (Hepatitis A,B,C and HIV)

MRSA Screening

Chemistry Haematology

Blood Group

The Patient is on the Transplant list
- for which country/organisation
YES / NO
EUROTRANSPLANT /
OTHER
**IMPORTANT NOTE**
Please note that the patient is responsible for his/her own medication
required during dialysis, eg. EPO, Iron, or if this will be provided by your
facility
For further information please do not hesitate to contact us;
Email; lux.fern@chl.lu
Phone; +352 44112373
Best regards