Focal Segmental Glomerulosclerosis Questionnaire

Your Name:
Q1:Are you a FSGS patient?:
Yes I have FSGS No my friend,relative or patient has FSGS
Q2:Is the patient male or female?
Male Female
Q3:How old is the patient?
Q4:How long since FSGS is found?
Q5:How is your kidney problem found?
A relative had kidney disease so I had myself checked
By accident in physical examination
Symptoms and then kidney disease was confirmed
Q6:What is the creatinine level?
Q7:What is the GFR level? (If you do not know your GFR, you can Test it now)
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?
Foamy urine/bubbly urine Edema/Swelling Hypoalbuminemia Hyperlipidemia High blood pressure
Others symptoms:
Q10:What complications the patient has?
Q11:What kind of treatments the patient has received?
Glucocorticoid Immunosuppressive agents Angiotensin converting anzyme inhibitior Angiotensin II receptor antagonists Lipid-lowing medicines Dialysis Kidney Transplant Other treatment
Q12:What information would you like to be given?

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