Form 2 Client pre-test, pot-test, and second post-tests for exp

ATTACHMENT 3 OMB#0925-XXXX

Exp. Date: XX/XXXX

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Participant ID #__________

NKDEP Evaluation – Client Pre-test and Post-test Survey

Circle one: □ Pre-test □ Post-test □ Second Post-test

Please check one box for each of the following statements:

	True	False	Don’t Know
				Diabetes is the main cause of kidney disease.
				High blood pressure affects the kidneys.
				Most cases of chronic kidney disease can be treated but cannot be cured.
				Most people can tell when they are first developing kidney disease because they usually have pain in their kidneys.
				It is important to get tested for kidney disease if you have diabetes, high blood pressure, heart disease, or a family history of kidney failure.
				Blood tests are recommended to check for kidney disease.
				Urine tests are not recommended to check for kidney disease.
				Diet changes, such as cutting back on salt, help to slow down kidney disease.
				Lifestyle changes, such as getting more exercise and losing weight, will not slow down kidney disease.
				Only doctors who are kidney specialists can treat early kidney disease.
				Kidney disease always leads to kidney failure.
				Dialysis is a treatment for kidney failure.

	Yes	No
13.			Has a doctor or health care professional ever told you that you have diabetes or a high blood pressure?
14.			Have you ever talked with your doctor or health care professional about your risks for kidney disease?
15.				Are you at risk for kidney disease?
16.				Have your doctor ever requested a blood or/and urine test to test for kidney disease?
17.				Are you familiar with materials/resources from the National Kidney Disease Education Program?

Participant ID #__________

NKDEP Evaluation – Client Pre-test and Post-test Survey

Circle one: □ Pre-test □ Post-test □ Second Post-test

18. How likely are you to see a health care professional regarding your kidney health?

a. Very likely

b. Likely

b. Somewhat likely

c. Not likely

19. Now I have some questions about your health, would you say your health is…

a. Excellent

b. Very good

c. Good

d. Fair

e. Poor

20. Comparing your health now with your health of two months ago, would you say your health now is…

a. Much better

b. Somewhat better

c. More or less the same

d. Somewhat worse

e. Much worse