Patient Education Resources - Dallas Nephrology Associates

PATIENT EMPOWERMENT FORMS

The more you know about CKD, the more empowered you will be.

Research shows that education improves the quality of life for patients with CKD. The more you know about CKD, the more empowered you’ll be to make smart choices and take steps to manage your health. To help you achieve better health, we created some handy tools to educate you about CKD and your health. These tools also make it easier to plan during every stage of CKD. All Empowerment Forms are downloadable and printable and are available in both English and Spanish.

My Information and My

Doctors’ Contact Information

A form titled "Keep Track" for noting personal and doctors' contact information. Fields include patient name, emergency contact, and various specialists (e.g., Nephrologist, Endocrinologist, Cardiologist). The form is branded with "Dallas Nephrology Associates" at the bottom.

My Current

Medications

A medication tracker form titled "Keep Track" by Dallas Nephrology Associates. It includes sections for patient name, name of medicine, date started, date stopped, dosage, times per day, prescribing doctor, and reason. The form is primarily blue and white.

My Important

Lab Values

A medical tracking sheet titled "My Important Lab Values" with columns for patient name, date, lab tests/scan, results, doctor, trend, and notes. One row is filled in with sample information. The sheet is branded with Dallas Nephrology Associates.

My Blood

Pressure Log

A blood pressure log sheet titled "Keep Track" with fields for Patient Name, Blood Pressure Readings (Systolic, Diastolic), Heart Rate, and Comments. The log includes a table for daily readings, and a footer with "Dallas Nephrology Associates" branding and notes.

My Blood

Glucose Log

A blood glucose log sheet with columns for date, meal times (breakfast, lunch, dinner, bedtime), blood glucose level entries, and medication/comments sections. Includes a sample row filled with timestamps and glucose readings. Branding of Dallas Nephrology Associates.

Summaries of

My Doctor Visits

A form from Dallas Nephrology Associates titled "Summaries of My Doctor Visits" with sections for "Date," "Doctor," "Reason for visit," "Summary of visit, including plan," and "Follow up." There are two sets of these sections on the form.

Copy of

My Advance Directive

An organized form to keep track of advance directives. Sections include "Living Will/Directive to Physicians," "Health Care Power of Attorney/Health Care Proxy," and "Revisions" with spaces to record dates and copies given. Dallas Nephrology Associates branding is shown.