Amyloid Nephropathy Health Assessment Questionnaire

Your Name *:
Country *:
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Phone(optional):
Q1:Are you an Amyloid Nephropathy patient?
Yes ,I have Amyloid Nephropathy No, my friend, relative or patient has Amyloid Nephropathy
Q2:Is the patient male or female?
Male Female
Q3:How old is the patient?
Q4:How long since Amyloid Nephropathy is found?
Q5:How is Amyloid Nephropathy found?
Q6:What is the creatinine level?
Q7:What is the GFR level?
Q8:What symptoms the patient has?
Proteinuria/Foamy urine Edema/Swelling Frequent urination Hypoproteinemia Hyperlipemia Catch cold easily Fatigue Poor immunity Poor appetite Fatigue/Tiredness Dizziness Nausea/Vomit
Others symptoms
Q9. What is the daily urine output?
Q10: What medicines is the patient taking now?
Q11: Has the patient start dialysis?
Yes No
Q11: If the above answer is yes, how long have you been on dialysis?
Q12: Are you waiting for a kidney donor?
Yes No
Q13:For any of your concerned information, you may leave us a message
Q14: Any other things you want to say?
 

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