Lupus Nephritis Questionnaire

Your Name *:
Country *:
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Phone(optional):
Q1:Do you have lupus nephritis?
Yes, I have lupus nephritis No, my friend, relative or patient has lupus nephritis
Q2:Is the patient male or female?
Male Female
Q3:How old is the patient?
Q4:How long since lupus nephritis is found?
Q5:Does anyone in your family have lupus nephritis?
Q6:Are you pregnant or not?
Yes No
Q7: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
Q8: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
Q9:What symptoms the patient has?
Proteinuria hematuria edema hypertension increased night urination renal tubular acidosis hypoalbuminemia renal failure
Others symptoms
Q10:What kind of treatments the patient has received?
Glucocorticoid prednisone cyclophosphamide azathioprine cyclosporineA tacrolimus dialysis plasma exchange
Q11:What information would you like to be given about lupus nephritis?

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