Duration of chronic kidney disease: Underlying renal disease:	_______________________________________
Diabetes Mellitus	Yes/No If yes, Duration______________
Hypertension	Yes/No If yes, Duration______________
Glomerulonephritis	Yes/No If yes, Duration______________
Nephrolithiasis	Yes/No If yes, Duration______________
Cystic kidney disease	Yes/No If yes, Duration______________
Congenital kidney disease	Yes/No
Other (Specify)
Laboratory examination (latest report within preceding 3 months:
Creatinine (mg/dL):
Hemoglobin (g/dL):
Urinalysis:
Urine protein estimation:
Ultrasound of kidneys:
Current antihypertensive regimen:
ACEi
ARBs
Alpha-blockers
Beta-blockers
CCBs
Diuretics
Others
Height:
Weight:
BMI: