Chronic Kidney Disease Follow-up Form
Patient Name
Patient ID
Date of Visit
Age
Gender
Male
Female
Other
CKD Stage
Stage 1
Stage 2
Stage 3a
Stage 3b
Stage 4
Stage 5
Current Symptoms
Vital Signs
Blood Pressure
Heart Rate
Weight (kg)
Laboratory Results
Serum Creatinine (mg/dL)
eGFR (ml/min/1.73m²)
Urine Protein
Medications
Adherence Issues
Recent Complications
Dietary Advice
Next Follow-up Date
Provider/Clinician
Additional Notes