IgA Nephropathy Questionnaire

Your Name *:
Country *:
Email *:
Phone(optional):
Q1:Do you have IgA Nephropathy (Berger's Disease)?
Yes, I have IgA No, my friend, relative or patient has IgA
Q2:Is the patient male or female?
Male Female
Q3:How old is the patient?
Q4:Does the patient have frequent upper respiratory tract infection?
Yes No
Q5:How long since IgA is diagnosed?
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?
90 - 120 mL/min/1.73 m2 60 - 90 mL/min/1.73 m2 15 - 60 mL/min/1.73 m2
Below 15 mL/min/1.73 m2 Do not know
Q8:What symptoms does the patient have?
Blood in urine bubble urine high blood pressure renal insufficiency tonsillitis
Others symptoms
Q9:Does the patient have the following systemic diseases?
Liver failure celiac disease rheumatoid arthritis
Reiter's disease ankylosing spondylitis
Others Diseases
Q10:Does the patient have the following risk factors?
Hypertension smoking hyperlipidemia familial disease
Q11:What kind of treatments the patient has received?
Steroids cyclophosphamide azathioprine mycophenolate mofetil ciclosporin mizoribine anticoagulants omega-3 fatty acids tonsillectomy
Q12:What information would you like to be given? (please write what you want to know more in the box below)
 

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