Kidney Function and Elimination Assessment Form
Please complete this form to help assess kidney function and elimination status. All questions are related to your current symptoms and habits.
How often do you urinate in a typical day?
*
Less than 3 times
3-6 times
7-10 times
More than 10 times
Do you experience difficulty starting urination?
*
Never
Rarely
Sometimes
Often
How would you rate the color of your urine?
*
Very pale/clear
Light yellow
Dark yellow
Amber or darker
Have you noticed any swelling in your legs, ankles, or feet?
*
No swelling
Mild swelling
Moderate swelling
Severe swelling
How much fluid do you typically drink in a day?
*
Less than 1 liter
1-2 liters
2-3 liters
More than 3 liters
Please indicate the presence and severity of the following symptoms in the past week.
*
Rows
None
Mild
Moderate
Severe
Fatigue
1
2
3
4
Lower back pain
5
6
7
8
Nausea
9
10
11
12
Loss of appetite
13
14
15
16
Do you ever notice blood in your urine?
*
Never
Rarely
Sometimes
Often
How would you rate the strength of your urine stream?
*
Very weak
1
2
3
4
Very strong
5
1 is Very weak, 5 is Very strong
Have you experienced any recent changes in your urination or elimination habits?
*
No changes
Changes in frequency
Changes in volume
Other changes
Please provide any additional comments or observations about your kidney function or elimination.
Submit Assessment
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