Polycystic Kidney Disease Questionnaire

Your Name:
Country:
Email:
Phone(optional):
Q1:Are you a PKD patient?:
Yes I have PKD No my friend, relative or patient has PKD
Q2:Is the patient male or female?
Q3:How old is the patient?
Under 18 18-30 30-45 45-60 Over 60
Q4:How long since PKD is found?
Less than 1 year 1-5 years 5-10 years Do not know
Q5:How is PKD found?
A relative had PKD so I had myself checked By accident in physical examination Symptoms and then it was confirmed Others
Q6:What is the size of the largest cyst?
Less than 1cm 1-3cm 3-5cm 5-10cm Above 10cm 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 is the daily urine output?
Above 2500ml 1500-2500ml 1000-1500ml 400-1000ml Below 400ml Do not know
Q10:What symptoms the patient has? (click all that apply)
Back pain flank pain abdominal pain blood in urine bubble in urine high blood pressure frequent urinary tract infection etc.
Others symptoms:
Q11:What complications the patient has? (click all that apply)
Cyst in other organs kidney stone abnormal heart valves aneurysms diverticulosis
Others Complications:
Q12:What kind of treatments the patient has received? (click all that apply)
pain killer anti-hypertension medicines antibiotics aspiration laparoscopic decortication dialysis kidney transplant
Others Treatment:
Q13:What information would you like to be given?
 

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