Membranous Nephropathy Questionnaire

Your Name *:
Country *:
Email *:
Phone(optional):
Q1:Do you have membranous nephropathy?
Yes, I have membranous nephropathy
No, my friend, family, or patient has membranous nephropathy
Q2:Is the patient male or female?
Male Female
Q3:How old is the patient?
Q4:How long since membranous nephropathy is found?
Q5:What is the daily protein in urine?
Less than 4g 4-8g Above 8g Do not know
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 the patient has?
Swelling fatigue poor appetite increased night urination blood clots infection bubble urine
Others symptoms:
Q9:What complications the patient has?
High blood pressure high blood cholesterol nephrotic syndrome acute kidney failure chronic kidney failure
Others Complications
Q10:What kind of treatments the patient has received?
ACEI diuretics immunosuppressant rituximab dialysis kidney transplant
Q11:What information would you like to be given? (please write what you want to know more in the box below)
 

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