Kidney Health Assessment Questionnaire for People with Diabetics

Name *:
Age *:
Email *:
Phone(optional):
Gender:Male Female
Q1:Do you have Diabetes?
Yes No a friend or relative has Diabetes
Q2:How long has the patient had Diabetes?
<1 year 1-3 year 3-8 years 8-15 years Over 15 years
Q3:Does the patient have high blood pressure?
Yes No
Q4:How well are blood sugar and blood pressure managed?
Most times in normal range but sometimes a bit higher The numbers fluctuate but I still can control them The numbers are at most times higher than normal range and I find great difficulty controlling them down
Q5:Has the patient done any kidney disease screening tests, such as urinalysis, microalbuminuria, or kidney function test?
Yes No
Q6:Does the patient have eye disease or have ever done laser treatment?
Yes No
Q7:Choose if the patient has any of the following early signs of kidney disease
Foams in urine
or proteinuria
Swelling in limbs
eyelids or ankles
Rising blood pressure
Increased night urination
Q8:What about the glomerular filtration rate (GFR) now?
90-120ml/min/1.73m2 60-90 ml/min/1.73m2 15-60ml/min/1.73m2 Below 15ml/min/1.73m2 Do not know
Q9:What about the 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
Q10:Choose if the patient has any of the following symptoms
Anemia Poor appetite Vomiting and nausea Shortness of breath Itchy skin Weakness Headaches
Other symptoms/ complications
Q11:What are your concerned questions?
Healthy living to protect the kidneys Analysis for individualized kidney condition Nursing care plan for diabetic kidney disease Prevention/ nursing for other diabetic complications (limb damage retinopathy heart disease etc)
Summary: Please enter any further details about the disease history, current conditions or your concerns here
 

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