Register To Receive The University of Colorado Health Science Center PKD Research Update and Notification of Research Studies For Which You May Qualify.
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Date:
Title: Mr. Ms. Mrs. Dr.
*First Name: Middle Initial:
*Last Name:
Maiden Name:
*Address:
*City:
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*Zip Code:
Home Phone Number (Please include area code):
Work Phone Number (Please include area code):
Cell Phone Number (Please include area code):
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The following questions will help us to determine your eligibility for current and future studies at the University of Colorado Health Sciences Center. You do NOT need to answer these questions to register for our mailing list. If you do not wish to answer these questions, please proceed to the end and press SUBMIT.
Date of Birth: (MM/DD/YYYY)
1. Do you have PKD?
Yes
No
Unknown
If yes, in what year were you diagnosed?
If yes, what was your method of diagnosis?
Ultrasound
CT-Scan
IVP (X-ray with dye infusion)
Other:
2. Reason for PKD diagnosis?
3. Which parent had PKD?
Mother
Father
Neither
If you do have an affected parent, is that parent alive?
4. Have you had dialysis treatment?
If yes, in what year was your first dialysis treatment?
5. Have you received a kidney transplant?
If yes, in what year was your first transplant?
6. Is/Was parent with PKD on dialysis?
7. Has/Had parent with PKD received a transplant?
8. Do you have high blood pressure or have you been treated for high blood pressure?
9. Did/Does your mother have high blood pressure?
10. Did/Does your father have high blood pressure?
11. Have you had any problems with strokes or bleeding in your head?
If yes, in what year did this occur?
What was the problem?
Stroke
Bleeding
Ruptured Aneurysm
12. Has anyone in your family had a ruptured aneurysm in their head?
Who?
Did that person have PKD?
13. How many of your living family members have been diagnosed with PKD?
14. Question for women only: Have you had complications during pregnancy such as increased blood pressure, protein in your urine, etc.?
15. Have you ever been diagnosed with diabetes?
16. Has anyone in your family donated a kidney to a family member, only to find out later that the donor had PKD?
17. Please indicate your Gender
Male
Female
18. Ethnic Category (Select One):
(Providing this information is voluntary)
Hispanic or Latino
Not Hispanic or Latino
Decline to Report
19. Racial Categories (Select One):
American Indian/Alaska Native
Asian
Native Hawaiian or Other Pacific Islander
Black or African American
White
More than one Race
QUESTIONS? Call Toll-free (877)-765-9297 or Email: pkd.nurse@uchsc.edu
If you have family members who are interested in our studies, please direct them to our web site.
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