kidney disease questionnaire is an important tool used as a test to measure patient’s understanding about kidney disease as well as its treatment. In most cases, respondents are individuals who have symptoms of kidney disease or those who already have related conditions. The kidney disease questionnaire has to be designed by health practitioners so as to ensure that necessary information is gathered from the respondents. It acts as an important tool to help health practitioners administer treatment to kidney disease patients. Shown below is a sample kidney disease questionnaire.

Sample Kidney Disease Questionnaire

Name __________________

Age ___________________

Occupation ________________

Generally how would you rate your health?

Excellent ___________

Very good ______________

Good _________________

Fair ____________________

Poor __________________

Give a yes or no answer for the following questions

Do you smoke cigarettes? ___________

Do you abuse any kind of drugs? __________________

Have you passed dark urine in the past month __________

Have you experienced back pain in the past six months? __________

Do you feel any discomfort when you urinate? _______________

Have you noticed hesitancy with urination in the past month _______

Have you been feeling lethargic in the past six months? ________

Have you noticed any traces of blood when you urinate?  ___________

Have you noticed your hand and feet swelling? _________________

Have you noticed puffiness around your eyes? _________________

When was the last time you had a medical examination _______________

Tick below the tests your physician carried out in your last medical examination

Blood test _____

Urine test ______

Scan ________

Ultrasound ___

Electrolyte _____