Instruction to select boxes : 1) check one or more boxes 2) check one box only

Version 4.1 (NRR 2015)

< RM 1000

RM 1000 - 3000

RM 3001 - 5000

RM 5001 - 10000

> RM 10000

14. Primary renal disease(s) :

15.

16.

17.

Specify details :(Please specify details in text box)

Glomerulonephrities, specify

Diabetes Mellitus

Hypertension

Obstructive uropathy, specify

ADPKD

Drugs / toxic nephropathy

Hereditary nephritis, specify

Unknown

Others, specify

TB (any site)

d. Anti HCV antibody :

Other Malaysian, specify:

2. Identification card number :

Specify details :

Bumiputra Sarawak, specify:

Foreigner, specify:Malaysian

Bumiputra Sabah, specify:

(Specify details in box)

NRR ID:

SDPID:

Not done Not done

SKMBT

Hep. B antigen (HBsAg)

Hep. B antibody (HBsAb)

18.

19.

20. 21.

22.

RCF (Wrist AVF)

BBF Non-cuffed Catheter

Cuffed Catheter

Native graft

i. Dialysate Used

Solution A (Acid) + Bicarbonate Powder

Solution A (Acid) & B (Bicarbonate)

ii. Delivered dialysate electrolytes

Low (≤ 1.0)

Calcium (mmo/L)

High (≥ 1.75)

Normal (1.1 - 1.75)

Central delivery system

g.

f. Haemodialysis dialysate

23.

24.

Standard CAPD

Daytime Ambulatory PD

Automated PD / CCPD / NIPD

Others, specify :

Product / connectology, specifyBrand Name

Andy Disc

Stay Safe

Sleep Sa

Lucenxia

fe

Others, specify :

Ultrabag

HomeChoice / Pro

Ultraset

Others, specify :

25.

yad .62

27.

Religious Group reimbursed, specifyGovernment centres

JPA reimbursed

Others, specify

Government subsidy

SOCSO reimbursed

b. NGO / Charity body fundeda. Government funded

e. Insurancec. Self-funded

d. Employer subsidised f. Other source, specify

Voluntary Group reimbursed, specify

Others, specify

Others, specify :

Intellis