Alport Syndrome Questionnaire

Your Name *:
Country *:
Email *:
Phone(optional):
Q1:Do you have Alport syndrome?
Yes, I have Alport syndrome No, my friend, relative or patient has Alport syndrome
Q2:Is the patient male or female?
Male Female
Q3:How old is the patient?
Q4:How long since Alport syndrome is found?
Q5:Does the patient have family history of Alport syndrome?
Yes No
Q6:What is the creatinine level?
0.5-1.2mg/dl 1.2-2.0mg/dl 2.0-4.0mg/dl 4.0-5.0mg/dl Above 5.0mg/dl Do not know
Q7:What is the GFR level?
90 - 120 mL/min/1.73 m2 60 - 90 mL/min/1.73 m2 15 - 60 mL/min/1.73 m2 Below 15 mL/min/1.73 m2 Do not know
Q8:What is the daily urine output?
Above 2500ml 1500-2500ml 1000-1500ml 400-1000ml Below 400ml Do not know
Q9:What symptoms the patient has?
Blood in urine bubbles in urine high blood pressure kidney failure
Others symptoms
Q10:What complications the patient has?
sensorineural hearing loss anterior lenticonus perimaeular dotand fleck retinopathy midpmeripheral retinopthy retardation Epstein syndrome Fechtner syndrome Sebastian syndrome diffuse leiomyomatosis
Others Complications
Q11:What kind of treatments the patient has received?
ACEI cyclosporine dialysis kidney transplant
Others Treatment
Q12:What information would you like to be given?
 

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