AV Fistula Access Assessment Form
Please complete this form to assess and document the condition of the patient's AV fistula for dialysis access.
Patient Full Name
*
First Name
Last Name
Date of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Patient Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Location of AV Fistula
*
Please Select
Left Arm
Right Arm
Other
Type of AV Fistula
*
Radiocephalic (Wrist)
Brachiocephalic (Elbow)
Brachio-basilic
Other
Physical Examination Findings
*
Rows
Present
Absent
Not Assessed
Thrill
1
2
3
Bruit
4
5
6
Aneurysm
7
8
9
Infection (Redness/Swelling)
10
11
12
Assessment of Fistula Maturity
*
Mature and Ready for Use
Immature
Thrombosed/Non-functioning
History of Complications (select all that apply)
Thrombosis
Infection
Steal Syndrome
Bleeding
None
Other
Comments / Additional Observations
Submit Assessment
Should be Empty: