** Denotes required information

Kidney Enrollment Form

Site Code: **       Accrual Number: **       Initials: **
Patient Key:
For a list of site codes, click here. If no middle initial, use 'X'. Patient Key will be of the form XXXXXX-000-XXX

General Information

Pre-Transplant Diagnosis:
Other Pre-Transplant Diagnoses:
Kidney Graft Type:

Clinical/Laboratory Findings

Blood Pressure:
mmHg Systolic /    mmHg Diastolic
BUN:

mg/dL
umol/L
Urea:

mg/dL
umol/L
Creat:

mg/dL
umol/L

GFR:
Urine Dipstick
for Protein:

24 Hour Urine Collection
Protein:


mg/dL
umol/L
24 Hour Urine Collection
Creat:


mg/dL
umol/L

Biopsies

Number of Biopsies Performed:
Note: complete a biopsy report for EACH biopsy