Chronic Kidney Disease Review

If you have been advised by the surgery to submit an annual review of your kidney symptoms, please use this form.

If your symptoms are deteriorating or you are having any concerns please make an appointment with our Nurse.

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?

Your Blood Pressure

Please provide a minimum of one blood pressure reading, up to a maximum of seven.

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 unit:
Weight unit:

Smoking

Smoking status *
Would you like help to give up smoking?

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? *

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