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Chronic Kidney Disease Questionnaire

Name:
Age:
Email:
Phone(optional):
Gender:Male Female
Q1: Have you ever been told to have kidney disease?:
Yes No
Q2: How long has it been since you were first diagnosed?
< 1 year 1-3 years > 5-10 years
Q3: Have you been told what caused your kidney disease
Q4: Choose if you ever had any of the following
Kidney problem at birth or in childhood
Hospitalization due to kidney failure
Kidney failure when hospitalized for another reason
Bladder or kidney infections
Difficulty emptying your bladder
Bladder or other urologic surgery
Radiation to the abdomen or pelvis
Chemotherapy for cancer
Family history of kidney disease
Blood in urine
Foamy urine
If you answered yes to any of the above, please enter more details here
Q5: Do you use regularly pains or anti-inflammatory medicines or NSAINS
Yes No
If yes, list the name and the dose of medicines here
Q6: Do you use herbal supplements?
Yes No
If yes, list them here
Q7: Do you have high blood pressure or take medicines for high blood pressure?
Yes No
Q8: Have you ever been told to have Diabetes or pre-diabetes?
Yes No
If the answer is yes, how long ago were you first diagnosed?
1 year 1-3 years 3-5 years 5-10 years
Q9: Have you ever been told you were anemic, had a low blood or hemoglobin count?
Yes No
Q10: Have you ever been told to have osteoporosis, osteopenia, brittle, thin or weak bones?
Yes No
Q11: How about your glomerular filtration rate (GFR) now?
90-120ml/min/1.73 m2 60-90ml/min/1.73m2 15-60ml/min/1.73m2 Below 15ml/min/1.73m2 Do not know
Q12:What about your serum creatinine level now?
0.5-1.2mg/dl 1.2-2.0mg/dl 2.0-4.0mg/dl 4.0-5.0mg/dl Above 5.0mg/dl Do not know
Summary: If you answered yes to any of the above, please enter any details you feel pertinent here
 

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