Uremia Questionnaire

Your Name *:
Country *:
Email *:
Phone(optional):
Q1:Do you have uremia?
Yes I have uremia No my friend relative or patient has uremia
Q2:Is the patient male or female?
Male Female
Q3:How old is the patient?
Q4:How long since uremia is diagnosed?
Q5:What is the urea nitrogen level?
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 is the daily urine output?
Above 2500ml 1500-2500ml 1000-1500ml 400-1000ml Below 400ml Do not know
Q9:What symptoms and complications the patient has?
Anorexia lethargy decreased mental acuity coma fatigue nausea vomiting cold bone pain itch shortness of breath seizure cramps
Others symptoms:
Q10:What kind of treatments the patient has received?
Western medicines traditional Chinese herbal medicines 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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