Focal Segmental Glomerulosclerosis Questionnaire

Your Name:
Country:
Email:
Phone(optional):
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?
Under 18 18-30 30-45 45-60 Over 60
Q4:How long since FSGS is found?
Less than 1 year 1-5 years 5-10 years Do not know
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
Others
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? (If you do not know your GFR, you can Test it now)
90 - 120 mL/min/1.73 m2 60 - 90 mL/min/1.73 m2 30 - 59 mL/min/1.73 m2
15 - 30 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?
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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