Patient
Consultation date (dd.mm.yyyy)*
Email*
Owner's name*
Animal's name*

 Signalment
Species*
Date of birth (mm.yyyy)
Sex
Breed
Weight

 History
Polydipsia / polyuria (PD / PU)
Loss of body weight
Reduced of irregular appetite
Haircoat changes
Vomiting
Lethargy
Exercise intolerance
Decline in sociability or other behavioral changes
Recent travel to regions endemic for infectious renal diseases
Current or previous therapy with effects on renal function
Blindness (especially sudden onset)

 Physical examination
Pale mucous membranes
Reduced skin turgor (dehydration)
Abnormal haircoat
Dental calculus, gingivitis, periodontitis
Oral ulcerations, stomatitis, helitosism azotemic breath
Abnormal renal palpation (small, firm and irregular or enlarged)
Abnormal rectal palpation (prostate and/or urethra)
High systemic arterial blood pressure
Ocular changes consistent with hypertensive
Decline in body weight or low body condition score
Evidence of osteodystrophy (e.g., pliable mandible, fractures without known trauma, bone pain)
Edema

 Laboratory - important findings
Blood creatinine value:
Blood pressure measurement
Blood bicarbonate or total CO2:
Blood phosphate:
PTH: pmol/L
Packed cell volume:
Potassium:

 Urine analysis
Protein dipstick examination:
Protein / creatinine ratio:
Protein / creatinine ratio: UP: (g/l)
Protein / creatinine ratio: UC:
Urine sediment exams:
Urine culture:
Specific gravity determined by refractometry: [1.234]

 Morphologic exams
Abnormal renal architecture on survey radiographs
Abnormal renal ultrasound findings
Abnormal biopsy diagnostic of renal disease

 Clinical evaluation
Clinical judgement of origin of azotemia:
Underlying extra-renal abnormalities
Hypertensive retinopathy
Left ventricular hypertrophy