• Yes
• No

Do you have high blood pressure?

• Yes
• No

Does a close family member have kidney disease?

• Yes
• No

Were you a preemie?

• Yes
• No

Are you over age 50?

• Yes
• No

Do you smoke?

• Yes
• No

Are you African American, Hispanic, Native American Asian?

• Yes
• No

 
Symptoms
Is your urine: a dark color, foamy, a larger or smaller amount than usual, or do you get up at night to urinate?

• Yes
• No

Do you feel very tired or have muscle weakness?

• Yes
• No

Do you feel cold all the time?

• Yes
• No

Do you have pale skin, gums, or nails?

• Yes
• No

Do you have metallic taste in your mouth?

• Yes
• No

Have you stopped wanting to eat meat, chicken, or fish?

• Yes
• No

Do you feel sick to your stomach or throw up a lot?

• Yes
• No

Do you have any swelling in your hands, stomach, feet, or face?

• Yes
• No

Does your skin itch all over?

• Yes
• No

Do you feel short of breath even when you’re not active?

• Yes
• No

Do you have frequent strep throat?

• Yes
• No

Do you suffer from muscle cramps often?

• Yes
• No