CKD Risk Assessment: Quick Questionnaire

The new patient questionnaire below can help you quickly identify patients who are at risk for chronic kidney disease (CKD).

Kidney damage occurs slowly over years and happens in both kidneys. This disease does not have symptoms at the early stages, so people don't realize that the damage is occurring until much later in the disease process, or until other conditions suggest a potential problem with the kidney.

In addition to people who drink alcohol excessively or those with a genetic predisposition, certain populations are also at increased risk for CKD. These groups include patients with:

• Diabetes
• High Blood Pressure
• Cardiovascular disease, such as heart disease or heart failure.

Patient Questionnaire: Chronic Kidney Disease

Answer the following questions to find out if you have "silent" kidney disease (which does not have many signs at the beginning), or if you are at risk for this serious, life-threatening condition.

Score each statement that is true for you. If a statement is not true, or you are not sure, use a zero. Then add up all the points.

I am between 50 and 59 years of age.

If yes, score 2: _____

I am between 60 and 60 years of age.

If yes, score 3: _____

I am 70 years or older.

If yes, score 4: _____

I am a woman.

If yes, score 1: _____

I had/have anemia.

If yes, score 1: _____

I have high blood pressure.

If yes, score 1: _____

I have diabetes.

If yes, score 1: _____

I have a history of congestive heart failure or heart failure

If yes, score 1: _____

I have circulation disease in my legs.

If yes, score 1: _____

I have protein in my urine.

If yes, score 1: _____

Interpreting the Score:

Total _____

If your total score is 4 or higher, you have a 1-in-5 chance of having chronic kidney disease. You should have a simple blood test, to see if you have early stages of the disease. Only your doctor can determine for sure if you have kidney disease. If your score is between 0 and 3, you probably don't have kidney disease. But if you belong to any group with increased risk of the disease, such as people with diabetes or cardiovascular disease, you should be tested once a year.

For more information call 800-697-6397.