Kidney Enquiry Form Name : City/Village : Age : Address: Mobile No. : Lab Investigation: HB : Blood Sugar : B.P : Serum Uric Acid : Blood Urea: Serum Creatanine: Your blood pressure?(Systolic) : Your blood pressure?(Diastolic) : Any family history of kidney disease? : Are you diabetic? : YesNo Your liquid input?(in 24hrs): Have you been on dialysis?:YesNo How long have you been on dialysis: If it is Heamodialysis - what is the frequency?(/week): Options CLINIC VISIT: COD: DEPOSIT: Caller Name: Remarks: Please prove you are human by selecting the House.