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1. When you had dialysis for the very first time, was it with:

When you had dialysis for the very first time, was it with:   Haemodialysis (HD)

Peritoneal Dialysis (PD)

Not Applicable

2. How is your kidney disease currently being treated?

	Haemodialysis (HD)	Peritoneal Dialysis (PD)	Not on Dialysis
Please select ONE option	Satellitehospitalhome How is your kidney disease currently being treated?   Please select ONE option   Haemodialysis (HD)	CAPDAPD (Machine) Peritoneal Dialysis (PD)	TransplantedDiagnosed as requiring dialysis soon Not on Dialysis

3. How long (in years and months) have you been treated by your current modality for kidney disease?

	Length of Time
Pre-Dialysis	1 month2 months3 months4 months5 months6 months7 months8 months9 months10 months11 months1 year1 year 1 month1 year 2 months1 year 3 months1 year 4 months1 year 5 months1 year 6 months1 year 7 months1 year 8 months1 year 9 months1 year 10 months1 year 11 months2 years2 years 1 month2 years 2 months2 years 3 months2 years 4 months2 years 5 months2 years 6 months2 years 7 months2 years 8 months2 years 9 months2 years 10 months2 years 11 months3 years4 years5 years6 years7 years8 years9 years10 years11 years12 years13 years14 years15 years16 years17 years18 years19 years20 years21 years22 years23 years24 years25 years26 years27 years28 years29 years30 years31 years32 years33 years34 years35 years How long (in years and months) have you been treated by your current modality for kidney disease?   Pre-Dialysis   Length of Time
Haemodialysis	1 month2 months3 months4 months5 months6 months7 months8 months9 months10 months11 months1 year1 year 1 month1 year 2 months1 year 3 months1 year 4 months1 year 5 months1 year 6 months1 year 7 months1 year 8 months1 year 9 months1 year 10 months1 year 11 months2 years2 years 1 month2 years 2 months2 years 3 months2 years 4 months2 years 5 months2 years 6 months2 years 7 months2 years 8 months2 years 9 months2 years 10 months2 years 11 months3 years4 years5 years6 years7 years8 years9 years10 years11 years12 years13 years14 years15 years16 years17 years18 years19 years20 years21 years22 years23 years24 years25 years26 years27 years28 years29 years30 years31 years32 years33 years34 years35 years Haemodialysis   Length of Time
Peritoneal Dialysis	1 month2 months3 months4 months5 months6 months7 months8 months9 months10 months11 months1 year1 year 1 month1 year 2 months1 year 3 months1 year 4 months1 year 5 months1 year 6 months1 year 7 months1 year 8 months1 year 9 months1 year 10 months1 year 11 months2 years2 years 1 month2 years 2 months2 years 3 months2 years 4 months2 years 5 months2 years 6 months2 years 7 months2 years 8 months2 years 9 months2 years 10 months2 years 11 months3 years4 years5 years6 years7 years8 years9 years10 years11 years12 years13 years14 years15 years16 years17 years18 years19 years20 years21 years22 years23 years24 years25 years26 years27 years28 years29 years30 years31 years32 years33 years34 years35 years Peritoneal Dialysis   Length of Time
Transplanted	1 month2 months3 months4 months5 months6 months7 months8 months9 months10 months11 months1 year1 year 1 month1 year 2 months1 year 3 months1 year 4 months1 year 5 months1 year 6 months1 year 7 months1 year 8 months1 year 9 months1 year 10 months1 year 11 months2 years2 years 1 month2 years 2 months2 years 3 months2 years 4 months2 years 5 months2 years 6 months2 years 7 months2 years 8 months2 years 9 months2 years 10 months2 years 11 months3 years4 years5 years6 years7 years8 years9 years10 years11 years12 years13 years14 years15 years16 years17 years18 years19 years20 years21 years22 years23 years24 years25 years26 years27 years28 years29 years30 years31 years32 years33 years34 years35 years Transplanted   Length of Time

4. During this treatment time, has anyone ever spoken to you about alternative dialysis options and the possibility of changing treatments?

During this treatment time, has anyone ever spoken to you about alternative dialysis options and the possibility of changing treatments?   Yes

No

I don’t know

Not applicable

5. Are you currently on the transplant waiting pool?

Are you currently on the transplant waiting pool?   Yes

No

I don’t know

6. Who referred you to a nephrologist or kidney specialist?

Who referred you to a nephrologist or kidney specialist?   General practitioner	Another specialist doctor	Other (please specify)
Details:

7. How useful was the information you received about kidney diseases or dialysis options from your nephrologist or kidney specialist?

How useful was the information you received about kidney diseases or dialysis options from your nephrologist or kidney specialist?   Very helpful Somewhat helpful Somewhat unhelpful

Not at all helpful I did not receive any information I don’t know

8. Was it ever suggested to you that a certain treatment option would not be suitable for you because of your social circumstances (e.g. living conditions, life style, work)?

Was it ever suggested to you that a certain treatment option would not be suitable for you because of your social circumstances (e.g. living conditions, life style, work)?   Yes

No

I don’t know