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Chronic kidney disease review

Chronic Kidney Disease Review

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

Your Health Information

Have you had any overnight hospital admissions relating to your kidneys in the past 12 months? *
Are you able to exercise? *
Has this changed since your last review?
We would like to know about your level of breathlessness: *
Has this changed since your last review? *

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

Please use this date format: DD/MM/YYYY.
Morning Measurement
/
Evening Measurement
/

Day 2

Please use this date format: DD/MM/YYYY.
Morning Measurement
/
Evening Measurement
/

Day 3

Please use this date format: DD/MM/YYYY.
Morning Measurement
/
Evening Measurement
/

Day 4

Please use this date format: DD/MM/YYYY.
Morning Measurement
/
Evening Measurement
/

Day 5

Please use this date format: DD/MM/YYYY.
Morning Measurement
/
Evening Measurement
/

Day 6

Please use this date format: DD/MM/YYYY.
Morning Measurement
/
Evening Measurement
/

Day 7

Please use this date format: DD/MM/YYYY.
Morning Measurement
/
Evening Measurement
/

Average Blood Pressure

This is automatically calculated for internal use only.

Morning Measurement

/
Evening Measurement
/

Height and Weight

Height unit:
Weight unit:

Smoking and Vaping

Smoking/Vaping Status: *
Would you like help to give up smoking/vaping?

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

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

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