High Creatinine Questionnaire

Your Name *:
Country *:
Email *:
Phone(optional):
Gender:Male Female
Q1:How old is the patient?
Under 18 years 18-30 years old 30-45 years old 45-60 years old
Over 60
Q2: What about the serum creatinine level now?
Q3:Have you been told what has caused the high creatinine?
Diabetic Nephropathy Hypertensive Nephropathy Lupus Nephritis Polycystic Kidney Disease Purpura Nephritis FSGS IgA Nephropathy Nephrotic Syndrome Amyloidosis Others
Q4:What is glomerular filtration rate (GFR) now?(get it teste if you don't know)
15-30ml/min/1.73m2 30-60ml/min/1.73m2 10-15ml/min/1.73m2 5-10 ml/min/1.73m2 Below 5ml/min/1.73m2
Q5: Has the patient started dialysis yet?
Yes No
Q6:If the above answer is yes, how long has the patient been on dialysis?
<3 months 3-6 months 6 months to one year 1-3 years 3-5 years 5-10 years Over 10 years
Q7: What is current daily urine output?
Above 2500ml 1500-2500ml 1000-1500ml 400-1000ml Below 400ml Don't know
Q8: Choose if the patient has any of the following symptoms
Anemia High blood pressure Weakness Swelling Proteinuria Blood in urine Nausea Itchy skin Increased night urination Heart Disease Poor appetite Bone fractures Shortness of breath
Others symptoms
Q9: Choose if you have any of the following concerned questions
Control high creatinine by healthy diet Analysis for individualized illness condition Information about kidney transplant Delay progression of kidney damage and prevent creatinine from further increasing Management of complications of kidney disease
Describe your current illness condition or how you feel in short words
 

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