CKD Risk Questionnaire
This questionnaire will help you determine whether you are at risk for developing CKD. Start now by answering the questions as they appear below. When you finish you’ll be able to print out a copy of your answers to take to your physician for discussion.
1
Do you have diabetes?
YES
NO
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1
Did You Know?
Diabetes harms small blood vessels in the kidneys. Diabetes mellitus is the most common cause of kidney failure in the US.
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2
Do you have high blood pressure?
YES
NO
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2
Did You Know?
High blood pressure (hypertension) is both a cause and a complication of chronic kidney disease.
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3
Are you over the age of 65?
YES
NO
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3
Did You Know?
People 65 years of age and older are more likely to develop CKD.
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4
Do you have a family history of chronic kidney disease?
YES
NO
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4
Did You Know?
Patients who have family members with CKD are at higher risk of developing the condition.
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5
Are you African American, Hispanic, Native American, Asian, or Pacific Islander?
YES
NO
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5
Did You Know?
Certain ethnicities in the US are at greater risk than others for the development of kidney failure.
- African Americans
- Hispanic Americans
- Native Americans
- Asian Americans
- Pacific Islanders
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6
Did your doctor ever tell you that you have an auto-immune disease, systemic infections, urinary tract infections, and/or urinary stones?
YES
NO
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Did You Know?
People who have been told by a doctor that they have any of these conditions are at greater risk of developing chronic
kidney disease.
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Your Personalized
Questionnaire Results
*Thank you for completing our CKD Risk Questionnaire; your answers are listed below:
Using print button below, you may print out a copy of your answers to take to your doctor to discuss.
- Do you have diabetes?
- Do you have high blood pressure?
- Are you over the age of 65?
- Do you have a family history of chronic kidney disease?
- Are you African American, Hispanic, Native American, Asian, or Pacific Islander?
- Did your doctor ever tell you that you have an auto-immune disease, systemic infections, urinary tract infections, and/or urinary stones?
*Note: This questionnaire does not cover all of the risk factors for CKD. The questionnaire covers some, but not all of the most common risk factors for the development of CKD. If you are worried about CKD and your kidney health you should speak with your doctor about your concerns. Only a doctor can perform tests to see if your kidneys are functioning properly.
Information for Your Doctor:
The National Kidney Foundation published the KDOQI Guidelines for the identification and treatment of chronic kidney disease in 2002. The Guidelines identify the following factors as significant for the development of CKD.
Clinical Factors:
- Diabetes
- Hypertension
- Family history of chronic kidney disease
- Auto-immune disease
- Urinary tract infections
- Urinary stones
- Lower urinary tract obstruction
- Neoplasia
- Recovery from acute kidney failure
- Reduction in kidney mass
- Exposure to certain drugs
- Low birth weight
Socio-demographic Factors:
- Older age
- Ethnic minority status—African American, Hispanic, Native American, Asian, or Pacific Islander
- Exposure to certain chemicals and environmental conditions
- Low income/education
For more information and resources please visit www.kidneywatch.org.
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