Kidney Failure Health Assessment Questionnaire

Your Name:
Q1:Are you a patient with kidney failure?:
Yes, I have kidney failure No, my friend, relative or patient has kidney failure
Q2:What has resulted in your kidney failure?
Diabetes Hypertensive Nephropathy Polycystic Kidney Disease Lupus Nephritis Purpura Nephritis IgA Nephropathy FSGS Amyloidosis Nephrotic Syndrome Others
Q3:How old is the patient?
Under 18 18-30 30-45 45-60 over 60 years old
Q4:What is the GFR level?
10-15 mL/min/1.73 m2 8-10 mL/min/1.73 m2 5-10 mL/min/1.73 m2
<5 mL/min/1.73m2 Not sure
Q5:What discomforts/complications are troubling you ?
Anemia High blood pressure Feeling very weak Bad mouth odor Swelling Proteinuria Nausea Vomiting Itchy skin Excessive night urination Heart disease Poor appetite Complications of Diabetes: foot ulcer, blurry vision ,heart disease
Other symptoms :
Q6:Have you started dialysis now ?
Yes No
Q7: If the above answer is yes, how long have you been on dialysis?
<3 months 3-6 months 6 months to one year 1-3 years 3-5 years 5-10 years Over 10 years
Q8 : What is daily urine output now?
Above 2500ml 1500-2500ml 1000-1500ml 400-1000ml Below 400ml Don't know
Q9:Are you waiting for a kidney donor?
Yes No
Q10:Choose if you have any of the following problems:
Hard to find proper foods to eat
Creatinine very high even after dialysis
Short of breath even after dialysis
Difficulty in controlling blood glucose
Find myself getting weak and weak
Difficulty in managing my condition when on dialysis
Q11:What do you think may help improve present health status?
Dietary adjustments
Do dialysis under an expert's guidance
Make some changes in medicines
Communicate with those around
Q12:For any of your concerned information, you may leave us a message
Latest news for treatment of kidney failure
Analysis for individualized illness condition
Management of complications in kidney failure
Proper dietary plan to improve health status
Improve quality of life on dialysis
Describe your current illness condition or how you feel in short words.

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