Clinical Information |
X-Ray Contrast Allergy? |
Yes |
No |
|
Other Medication Allergy? |
Yes |
No |
|
Blood Thinner or Bleeding Disorders? |
Yes |
No |
|
Contagious Diseases ? |
|
|
|
|
Has patient had surgical revision of graft / fistula in last 4 weeks? |
Yes |
No |
|
Known problem with anesthesia? |
Yes |
No |
|
Competent to sign consent form? |
Yes |
No |
|