Renal Function Exam Intake Questionnaire
Please complete this questionnaire to help us assess your kidney health and prepare for your renal function exam.
Patient Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Contact Information (Email)
*
example@example.com
Contact Information (Phone Number)
*
Please enter a valid phone number.
Format: (000) 000-0000.
Referring Physician (if applicable)
Do you currently have or have you ever had any of the following conditions?
*
High blood pressure (hypertension)
Diabetes
Kidney disease or kidney stones
Heart disease
Liver disease
None of the above
Other
Please indicate if you are currently experiencing any of the following symptoms:
*
Swelling of the legs, ankles, or feet
Fatigue or weakness
Changes in urination (frequency, color, amount)
Shortness of breath
Nausea or vomiting
None of the above
Other
Please list any current medications you are taking (include prescription, over-the-counter, and supplements):
*
Do you have any allergies to medications or substances?
*
Yes
No
If yes, please list your allergies:
Lifestyle Factors
*
Rows
Yes
No
Do you smoke?
1
2
Do you consume alcohol?
3
4
Do you follow a special diet?
5
6
Have you had any recent blood or urine tests related to kidney function?
*
Yes
No
If yes, please upload your most recent test results (optional)
Upload a File
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On a scale of 1 to 5, how would you rate your current overall health?
*
Poor
1
2
3
4
Excellent
5
1 is Poor, 5 is Excellent
Submit
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