Kidney Health Questionnaire

Before We Begin

Please confirm your eligibility to complete this screening.

Are you 18 years of age or older? *

Yes No

Are you currently residing in Canada? *

Yes No

Consent & Privacy Notice

This questionnaire is part of the MyKidneyCare kidney health education initiative. Your participation helps improve kidney health education in Canadian communities.

How your information will be used:

Stored securely on Canadian servers, encrypted at rest
Used only for kidney health assessment and research
Never sold or shared with third parties for commercial purposes
Retained per our privacy policy; you may delete your data at any time

Right to withdraw: Participation is entirely voluntary. You may stop at any time without affecting any care you receive. You may request deletion of all your information at any time.

View Full Privacy Notice | Manage / Delete My Data

I consent to the collection, storage, and use of my personal health information to receive kidney health recommendations, as described above. *

I also consent to my de-identified data being used for health research purposes. This is optional. Declining does not affect your recommendations.

Part 1 of 3: Contact Information

Required fields are marked with *. Optional fields may be left blank or marked "Prefer not to share."

First Name * Letters, spaces, hyphens, and apostrophes only (e.g., Mary-Jane, O'Brien)

Last Name * Letters, spaces, hyphens, and apostrophes only (e.g., Singh-Patel, MacDonald)

Date of Birth *

Sex *

Female Male Other

Email Address *

Used only to send appointment reminders if you opt in, and to fulfil data-removal requests.

Phone Number *

Format: (###) ###-#### — digits are auto-formatted as you type

Postal Code *

Format: A1A 1A1 — letter, digit, letter, space, digit, letter, digit (auto-formatted)

Before We Begin

Visit History

Part 1 of 3: Contact Information

Part 2 of 3: Background Information

Part 3 of 3: Medical History