Chronic kidney disease review

Have you received a letter, text message or verbal invitation to complete this assessment? *

Yes

No

Your Health Information

Have you had any overnight hospital admissions relating to your kidneys in the past 12 months? *

Yes

No

In which months were you admitted to hospital?

Are you able to exercise? *

Yes

No

What limits your exercise?

What exercise do you do?

Has this changed since your last review?

Yes

No

We would like to know about your level of breathlessness: *

I only get breathless with strenuous exercise

I get breathless when hurrying on level ground or up a slight hill

I walk slower than people my age when walking on level ground because of breathlessness or have to stop to catch my breath when walking on level ground

I stop for breath after walking 100 yards or every few minutes

I am too breathless too leave the house most of the time

Has this changed since your last review? *

Yes

No

Your Blood Pressure

Please provide at least seven days of blood pressure readings.

If you do not have access to a home blood pressure device, please visit the practice and use the machine in our waiting area and then submit this form.

Day 1

Date: *

Please use this date format: DD/MM/YYYY.

Morning Measurement

Systolic “Higher” *

/

Diastolic “Lower” *

Heart Rate *

Evening Measurement

Systolic “Higher” *

/

Diastolic “Lower” *

Heart Rate *

Day 2

Date:

Please use this date format: DD/MM/YYYY.

Morning Measurement

Systolic “Higher”

/

Diastolic “Lower”

Heart Rate

Evening Measurement

Systolic “Higher”

/

Diastolic “Lower”

Heart Rate

Day 3

Date:

Please use this date format: DD/MM/YYYY.

Morning Measurement

Systolic “Higher”

/

Diastolic “Lower”

Heart Rate

Evening Measurement

Systolic “Higher”

/

Diastolic “Lower”

Heart Rate

Day 4

Date:

Please use this date format: DD/MM/YYYY.

Morning Measurement

Systolic “Higher”

/

Diastolic “Lower”

Heart Rate

Evening Measurement

Systolic “Higher”

/

Diastolic “Lower”

Heart Rate

Day 5

Date:

Please use this date format: DD/MM/YYYY.

Morning Measurement

Systolic “Higher”

/

Diastolic “Lower”

Heart Rate

Evening Measurement

Systolic “Higher”

/

Diastolic “Lower”

Heart Rate

Day 6

Date:

Please use this date format: DD/MM/YYYY.

Morning Measurement

Systolic “Higher”

/

Diastolic “Lower”

Heart Rate

Evening Measurement

Systolic “Higher”

/

Diastolic “Lower”

Heart Rate

Day 7

Date:

Please use this date format: DD/MM/YYYY.

Morning Measurement

Systolic “Higher”

/

Diastolic “Lower”

Heart Rate

Evening Measurement

Systolic “Higher”

/

Diastolic “Lower”

Heart Rate

Average Blood Pressure

This is automatically calculated for internal use only.

Morning Measurement

Systolic “Higher”

/

Diastolic “Lower”

Heart Rate

Evening Measurement

Systolic “Higher”

/

Diastolic “Lower”

Heart Rate

Height and Weight

Height:

Height unit:

Inches

CM

Weight:

Weight unit:

Stone

KG

Smoking and Vaping

Smoking/Vaping Status: *

Current smoker/vaper

Never smoked/vaped

Ex-smoker/vaper

How many cigarettes do you smoke per day, how often do you vape per day and at what nicotine strength or how much tobacco in grams do you use per week?

Would you like help to give up smoking/vaping?

Yes

No

For more information and help to give up smoking, please visit: www.quitwithhelp.co.uk

How many cigarettes did you smoke per day, how often did you vape per day and at what nicotine strength or how much tobacco in grams did you use per week?

When did you give up smoking/vaping?

Alcohol Consumption

This is one unit of alcohol:

And each one of these, is more than one unit:

How often do you have a drink containing alcohol? *

How many units of alcohol do you drink on a typical day when you are drinking? *

How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year? *

Contacting you

If we need to contact you to discuss anything related to your form when is the best time to contact you? *

E.g. Monday AM/PM, Tuesday AM/PM

Confirmation *

I confirm that the information provided is accurate to the best of my knowledge

Tell us whether you accept cookies

Your Health Information

Your Blood Pressure

Day 1

Day 2

Day 3

Day 4

Day 5

Day 6

Day 7

Average Blood Pressure

Height and Weight

Smoking and Vaping

Alcohol Consumption

This is one unit of alcohol:

And each one of these, is more than one unit:

Contacting you