Creatinine Clearance Assessment Form
Please provide the following information to estimate creatinine clearance and assess kidney function.
Patient Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Male
Female
Other
Weight (kg)
*
Height (cm)
*
Serum Creatinine (mg/dL)
*
Urine Creatinine (mg/dL)
*
Urine Volume Collected (mL)
*
Urine Collection Time (hours)
*
Relevant Medical History
History of kidney disease
Diabetes
Hypertension
Use of nephrotoxic medications
None of the above
Other
Please rate the patient's current hydration status:
Well hydrated
Mildly dehydrated
Severely dehydrated
Unknown
Are there any recent changes in patient's medications?
Yes
No
Additional Notes (if any)
Submit Assessment
Should be Empty: