Acute Kidney Failure Assessment Form
Assess current symptoms, relevant history, and urgency related to acute kidney failure concerns. Use the exact title consistently across the form.
Patient Background
Date of Birth
-
Month
-
Day
Year
Date
Sex at Birth
Female
Male
Intersex
Prefer not to say
Who is completing this form?
*
Patient
Caregiver
Parent/Guardian
Relative
Other
Current Symptoms and Timeline
Symptom onset date/time
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Symptom severity
*
Mild
1
2
3
4
5
6
7
8
9
Severe
10
1 is Mild, 10 is Severe
Current symptoms present
*
Reduced urine output
Swelling
Shortness of breath
Nausea or vomiting
Fatigue
Confusion
Flank pain
Signs of dehydration
Relevant Medical History and Risk Factors
Known kidney disease
None known
Chronic kidney disease
Kidney stones
Recurrent kidney infections
Other
Relevant risk factors and recent exposures
Diabetes
High blood pressure
Recent infection
Recent surgery
Recent injury
Dehydration
New medication or dose change
Herbal or over-the-counter products
Recent contrast imaging
Other
Assessment Summary and Urgency
Urgency Level
*
Mild
Moderate
Urgent
Needs immediate attention
Clinical Notes
Submit
Should be Empty: