VR3111 End-Stage Renal Disease Evaluation



Texas Workforce CommissionVocational Rehabilitation ServicesEnd-Stage Renal Disease Evaluation FORMTEXT ?The information requested is necessary to help counselors determine eligibility and/or a plan for rehabilitation services for the person named. FORMTEXT ?Return InformationReturn Report To (Name): FORMTEXT ?????Telephone Number:( FORMTEXT ???) FORMTEXT ?????Address: FORMTEXT ?????City: FORMTEXT ?????State: FORMTEXT ?????ZIP Code: FORMTEXT ?????Patient InformationName: FORMTEXT ?????Date of Birth: FORMTEXT ?????Case ID Number: FORMTEXT ?????Telephone Number: ( FORMTEXT ???) FORMTEXT ?????Reported Disability: FORMTEXT ?????Reason for Referral: FORMTEXT ?????Medical HistoryCondensed medical history: FORMTEXT ?????Diagnosis: FORMTEXT ?????Etiology (enter X to select all that apply): FORMTEXT ?? Glomerulonephritis FORMTEXT ?? Diabetes mellitus FORMTEXT ?? Interstitial nephritis FORMTEXT ?? Polycystic disease FORMTEXT ?? Nephrosclerosis FORMTEXT ?? Lupus erythematosus FORMTEXT ?? Malignant hypertension FORMTEXT ?? Other (specify): FORMTEXT ?????Associated abnormality (enter X to select all that apply): FORMTEXT ?? Uremia FORMTEXT ?? Osteoporosis FORMTEXT ?? Anemia FORMTEXT ?? Peripheral neuropathy FORMTEXT ?? Hyperparathyroidism FORMTEXT ?? Other(s) (list): FORMTEXT ?????Physical ExamHeight: FORMTEXT ?????Weight: FORMTEXT ?????Blood Pressure: FORMTEXT ?????/ FORMTEXT ?????Pulse: FORMTEXT ?????Respiration: FORMTEXT ?????Vision(Snellen)R: 20/ FORMTEXT ?????L: 20/ FORMTEXT ????? (with glasses, if available)R: 20/ FORMTEXT ?????L: 20/ FORMTEXT ????? Abnormal findings: FORMTEXT ?????Laboratory DataGlomerular Filtration Rate (GFR): FORMTEXT ?????Hemoglobin: FORMTEXT ?????Serum creatinine: FORMTEXT ?????BUN: FORMTEXT ?????Hematocrit: FORMTEXT ?????Present Treatment FORMTEXT ?? Hemodialysis FORMTEXT ?? CAPD FORMTEXT ?? Intermittent peritoneal dialysis FORMTEXT ?? Kidney transplant FORMTEXT ?? Other FORMTEXT ?????If on hemodialysis, can dialysis schedule be changed to accommodate work or training schedule? FORMTEXT ?? Yes FORMTEXT ?? NoIndicate type of AV shunt, if present: FORMTEXT ?????History of problems with shunt? FORMTEXT ????? Prescribed MedicationsPrescribed Medications/DosageIndications (Purpose)Possible Side Effects FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Treatment side effects and/or symptoms following dialysis: FORMTEXT ?????Physical and Functional LimitationsType X to select your opinion of current physical capabilities:Walking (level): FORMTEXT ?? Unlimited FORMTEXT ?? 1-2 miles FORMTEXT ?? ?-1 mile FORMTEXT ?? 1-2 blocks FORMTEXT ?? 100 ft. or lessLifting (more than 3 times per hour in an 8-hour workday): FORMTEXT ?? 60-100 lbs. FORMTEXT ?? 40-60 lbs. FORMTEXT ?? 25-40 lbs. FORMTEXT ?? 10-25 lbs. FORMTEXT ?? 10 lbs. or lessStanding: FORMTEXT ?? 6-8 hr /workday FORMTEXT ?? 4-6 hr /workday FORMTEXT ?? 2-4 hr /workday FORMTEXT ?? 0-2 hr /workdayOther functional limitations (please describe): FORMTEXT ?????Working conditions. Type X to select any condition to be avoided: FORMTEXT ?? Outdoors FORMTEXT ?? Indoors FORMTEXT ?? High humidity FORMTEXT ?? Dry FORMTEXT ?? Dusty FORMTEXT ?? Marked temperature changes FORMTEXT ?? Other: FORMTEXT ?????Special considerations and precautions: FORMTEXT ?????Recommendations and remarks: FORMTEXT ?????All information is to be treated as confidential.Examinee has the legal right to see this report when the examinee requests.Type or Print Physician's Name: FORMTEXT ?????Telephone Number:( FORMTEXT ???) FORMTEXT ?????Address: FORMTEXT ?????City: FORMTEXT ?????State: FORMTEXT ?????ZIP Code: FORMTEXT ?????Examining Physician Signature:X FORMTEXT ?????Date of Examination: FORMTEXT ????? ................
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