If you are caring for or have cared for a CAPD patient who is or was pregnant,
please help us in systematically collecting information about such patients.
Use file-save to save this form to disk.
Fill out the form and return it to Dr. Susan Hou, Rush Medical Center by email:
molitch@merle.acns.nwu.edu (Susan Hou)
Patient/Unit Information Form
1. How many women aged 14-44 are currently being dialyzed in your unit?
on CAPD?
on Hemodialysis?
2. Has your unit ever dialyzed a pregnant woman?
3. Has this pregnancy been reported to the registry previously?
4. Did any woman in your unit become pregnant between 1992 and 1994?
5. What were the outcomes of all pregnancies in your unit?
6. What were the modalities of dialysis in women who were dialyzed during pregnancy?
at conception?
during pregnancy?
Name of the person filling out this form: ____________________________
Dialysis unit
Telephone number
Address
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