Diabetic Kidney Evaluation Form
Use this form to share the information needed for a diabetic kidney evaluation.
Patient and Evaluation Details
Patient full name
*
First Name
Last Name
Date of birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Evaluation date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Diabetes type
*
Type 1
Type 2
Gestational
Other
Years since diabetes diagnosis
*
Current reason for evaluation
Kidney and Diabetes Status
Latest HbA1c (%)
Recent blood pressure reading
Known kidney condition status
Please Select
None known
CKD stage 1
CKD stage 2
CKD stage 3
CKD stage 4
CKD stage 5
Dialysis
Not sure
Presence of protein in urine / albuminuria
Yes
No
Not sure
Current diabetes medications
Symptoms, Risk Factors, and Notes
Current symptoms
*
Swelling
Foamy urine
Frequent urination
Fatigue
Nausea
Decreased appetite
None
Additional clinician notes or recent lab findings
Submit
Should be Empty: