Dialysis History

This form captures information about the patient’s peritoneal and hemodialysis

history.

The date of dialysis initiation, dialysis modality, dialysis prescription, dialysis access and date of access placement should be provided.

Please add a new row for each additional dialysis-related outcome. Include important information about the complication, date of onset, days from dialysis initiation, date of resolution, and days from dialysis initiation.

• If the date of dialysis is unavailable, use July 1 with the approximate year of diagnosis. If an exact year is not available, an approximation is acceptable. If any approximations are used, please make a note in the comments section.

• Once the date is entered, please click on the calculator to calculate the age at the time of the INDEX diagnosis date, age at the time of dialysis initiation, and days from the date of dialysis initiation.