Kidney Health Nutrition Programme Kidney Health Nutrition Programme Name Name First Name First Name Last Name Last Name Email Phone Date of Birth * Gender * MaleFemaleNon-BinaryPrefer Not to Say Do you have a diagnosed kidney condition? Yes No If yes, what is your diagnosis? Stage of Chronic Kidney Disease (CKD), if known Stage 1 (Mild)Stage 2 (Mild to Moderate)Stage 3 (Moderate)Stage 4 (Severe)Stage 5 (Kidney Failure)On DialysisNot Sure Are you currently on dialysis? Yes No Do you have any other medical conditions? Diabetes High Blood Pressure Heart Disease Gout Other Other Are you currently taking any medications related to kidney health? Current Diet Type Low-Sodium Diet Low-Protein Diet High-Protein Diet Plant-Based Diet Standard Diet Other Other Are you following any dietary restrictions? Low-Potassium Diet Low-Phosphorus Diet Low-Sodium Diet Dairy-Free Gluten-Free No Restrictions Other Other How much water do you consume daily? Biggest Dietary Challenges Managing Sodium Intake Controlling Protein Consumption Balancing Potassium & Phosphorus Levels Meal Planning & Preparation Lack of Energy & Appetite Other Other Meal Plan Preferences Low-Sodium, Kidney-Friendly Meals Low-Protein Balanced Diet Plant-Based Kidney Health Diet Dialysis-Friendly Meal Plans No Specific Preference Would you like guidance on managing fluid intake? Yes No Would you like kidney-friendly snack recommendations? Yes No Do you require help with meal preparation? Yes No Would you like additional guidance on managing blood pressure or diabetes alongside kidney health? Yes No Support My Kidney Health Package Selection Basic Meal PlanPersonalized Plan with Dietitian ConsultationPremium Support with Weekly Adjustments Payment Terms and Condition * I confirm that the information provided is accurate, and I agree to the terms of the Kidney Health Nutrition Programme. If you are human, leave this field blank.
