Kidney stone questionnaire

Your Name *:
Country *:
Email *:
Q1:What is your occupation?
Q2:How many kidney stones have you had in the past?
Q3: If you had kidney stone, answer the following questions a-d:
a) Were you able to pass them spontaneously?
Yes No
b) Did you require open surgical removal?
Yes No
c) Did you have them extracted with telescope instruments form inside?
Yes No
d) Did you ever have stones treated by lithotripsy (ESWL-shock wave treatment)?
Yes No
Q4: Is there a family history of stones?
Yes No
If yes, in which relative(s)?
Q5: Choose if you take any of the following medications regularly?
Antacids (Rolaids Tums) Vitamins (Vitamin C D) Neither
Q6: Do you currently have retained kidney stones?
Yes No
Q7: Have you ever had any of the following illnesses:
Gout High Blood pressure Ulcers Kidney Infection Bladder Infection None
Q8: On the average, how many cups/glasses of each of the following do you have per day:
Milk or Milk Products
Colas (Coke, Pepsi, etc.)
Coffee or Tea:
Cranberry Juice:
Q9:Do you eat chocolate almost daily?
Yes No
Q10:Do you eat nuts almost daily?
Yes No
Q11: Do you eat red meat daily?
Yes No
Q12: Do you eat salty snacks regularly?
Yes No
Q13: Do you eat fiber (bran) regularly?
Yes No
Q14:Were you put on any medication to prevent future stones? If any, write them down:
Q15:List any other pertinent information you may have regarding your kidney stones?

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