Please answer if you have or have had any of the below listed conditions, medications or investigations to the best of your knowledge prior to the consultation. If answered with 'yes', please give details as appropriate.

1) Risk factors for CKD:

- Hypertension?

- Diabetes?

- Glomerular disease (e.g. acute glomerulonephritis)?

- Current or previous history of acute kidney injury (AKI)?

- Potentially nephrotoxic drugs?

--- Aminoglycosides?

--- Angiotensin-converting enzyme (ACE) inhibitors?

--- Angiotensin II receptor antagonists (AIIRAs)?

--- Bisphophonates?

--- Calcineurin inhibitors (such as ciclosporin or tacrolismus)?

--- Diuretics?

--- Lithium?

--- Mesalazine?

--- Nonsteroidal anti-inflammatory drugs (NSAIDs)?

- Conditions associated with obstructive uropathy?

--- Structural renal tract disease?

--- Bladder voiding problems (e.g. neurogenic bladder, benign prostatic hypertrophy)?

--- Urinary diversion surgery?

--- Recurrent urinary tract calculi?

- Multisystem disease with potential renal involvement?

--- Systemic lupus erythematosus (SLE) (which may cause lupus nephritis)?

--- Vasculitis?

--- Myeloma?

- Family history of CKD stage 5?

- Hereditary kidney disease (e.g. autosomal dominant polycystic kidney disease, Alport's syndrome and familial glomerulonephritis)?

- Cardiovascular disease?

- Obesity with metabolic syndrome?

- Gout?

2) Incidental finding of:

- Blood test with raised serum creatinine and/or serum estimated glomerular filtration rate (eGFR) < 60 ml/min/1.73 m2?

- Protein in the urine (proteinuria) (urinary albumin to creatinine ratio (uACR) > 3 mg/mmol))?

- Blood in the urine (haematuria) (persistent haematuria (two or of three urine dipstick tests show 1+ or more of blood) after exclusion of a urinary tract infection (UTI)?

- Urine sediment abnormalities (eg red blood cells (may indicate glomerular disease), white blood cells (may indicate pyelonephritis or interstitial nephritis) or granular casts and renal tubular epithelial cells (seen in many parenchymal diseases)?

3) Possible clinical features of CKD:

- General symptoms:

--- Lethargy?

--- Itch?

--- Breathlessness?

--- Cramps (often worse at night)?

--- Sleep disturbance?

--- Bone pain?

--- Loss of appetite?

--- Vomiting?

--- Weight loss?

--- Taste disturbance (often present with end-stage disease)?

- Urine output exceeding 3 L/day (polyuria)?

- Need to get up at night on a regular basis to urinate (nocturia)?

- Urine output less than 100 mL/day (anuria)?

- Obstructive uropathy causing urinary retention?

- End-stage renal disease?

- Co-morbidities or complications of CKD?

--- Acute kidney injury?

--- Hypertension?

--- Dyslipidaemia?

--- Cardiovascular disease such as ischaemic heart disease, heart failure, stroke and peripheral arterial disease?

--- Renal anaemia (haemoglobin less than 11 g/dl)?

--- Renal mineral and bone disorder?

--- Peripheral neuropathy and myopathy?

--- Malnutrition? - Clinical features of anxiety:

Have you experienced excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance)?

- Clinical features of depression:

During the last month, have you often been bothered by feeling down, depressed, or hopeless?

During the last month, have you often been bothered by having little interest or pleasure in doing things?

If you answered 'yes' to one of the above 2 questions, please also answer if following symptoms have been present most days, most of the time, for at least 2 weeks:

Disturbed sleep (decreased or increased compared to usual)?

Decreased or increased appetite and/or weight?

Fatigue or loss of energy?

Agitation or slowing down of movements and thoughts?

Poor concentration or indecisiveness?

Feelings of worthlessness or excessive or inappropriate guilt?

Recurrent thoughts of death, recurrent suicidal ideas, or a suicide attempt or specific plan?