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End Stage Renal Disease (ESRD) Questionnaire

This questionnaire is aimed at providing some guidance for people with ESRD, their family and friends. After you submit the questionnaire, there will be free and detailed analysis for your specific illness condition, which can help you better understand your current condition. We also provide suggestions on your daily health care, prevention and treatment. Do not forget to leave your email address here or we can not send the illness analysis to you! We agree with personal privacy protection and promise not to reveal your info to anybody.

Patient Information

1. Are you the patient with ESRD?

Yes, I have.  No, my friend, relative or patient has.
2. Is the patient a male or female?

Male Female
3. How old is the person with ESRD?

Under 18 18-30 30-45 45-60 Over 60
4. What are the causes of ESRD?

Diabetes High blood pressure Polycystic Kidney Disease (PKD) FSGS Nephrotic Syndrome IgA Nephropathy Lupus Nephritis Purpura Nephritis Others
5. What is the GFR or kidney function?

10 -15 mL/min/1.73 ㎡ 8 - 10 mL/min/1.73 ㎡ 5 - 8 mL/min/1.73 ㎡ Less than 5 mL/min/1.73 ㎡ Not clear
6. Discomforts or symptoms of the patient

Anemia High blood pressure Weak or tiredness Bad odor of mouth Swelling Protein in urine Nausea and/or Vomiting Itching skin Increased urination at night Heart disease Loss of appetite
Other symptoms:

7. Is the patient undergoing dialysis now?

Yes Not yet
8. How long has the patient on dialysis?

Less than 3 months 3-6 months 6 months to 1 year 1-3 years 3-5 years 5-10 years More than 10 years
9. What is the urine output per day?

≥2500ml 1500-2500ml 1000-1500ml 400-1000ml ≤400ml
10. You can add more information that can be helpful for our analysis:

    Your Name: *

    Country: *

    Email: *

    Phone: (optional)

About Us

Unlike any other charity, we can offer a comprehensive menu of outpatient, hospital-based and Web offerings that enable use to provide the ongoing support for children and families--from diagnosis through the entire medical treatment course. We can help them relieve their pain and manage their illness better.