Dialysis Questionnaire

Your Name *:
Country *:
Email *:
Phone(optional):
Q1:Is the patient male or female?
Male Female
Q2:What is the patient'age?
Under 18 18-30 30-45 45-60 Over 60
Q3:Have the patient started dialysis?
Q4:How long since dialysis is started?
Q5:What is the creatinine level when dialysis is started?
Q6:What is the kidney disease that leads to dialysis?
Q7:Is it hemodialysis or peritoneal dialysis?
hemodialysis peritoneal dialysis
Q8:What is the GFR? (If you do not know your GFR, you can test it now)
higher than 90 mL/min/1.73 m2 60–89 mL/min/1.73 m2 30–59 mL/min/1.73 m2
15–29 mL/min/1.73 m2 lower than 15 mL/min/1.73 m2
Q9:What is the current creatinine level?
Q10:What is the daily urine output now?
Above 2500ml 1500-2500ml 1000-1500ml 400-1000ml Below 400ml Do not know
Q11:Do you have the following symptoms or complications of dialysis?
Nausea vomiting dysphoria coma hypotension high fever arrhythmia heart failure muscle spasm
Others symptoms:
Q12:What information would you like to know?
 

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