Nephritis Questionnaire

Your Name *:
Country *:
Email *:
Phone(optional):
Q1:Are you a nephritis patient?
Yes I have nephritis
No my friend relative or patient has nephritis
Q2:Is the patient male or female?
Male Female
Q3:How old is the patient?
Q4:How long since nephritis is diagnosed?
Q5:Is it primary nephritis or secondary nephritis?
Primary nephritis Secondary nephritis
Q6:Do you know the original cause of nephritis?
Infections Toxins Systemic lupus erythematosus (SLE) Purpura Strenuous exercises Do not know
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 and complications the patient has?
Infections oliguria anuria hematuria edema hypertension renal damages proteinuria blood clots
Others symptoms:
Q10:What kind of treatments the patient has received?
Diuretics anticoagulants anti-hypertension medicines antibiotics dialysis kidney transplant
Others Treatment
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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