NASH / NAFLD Survey

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* 1. Why are you interested in Fatty Liver Disease

I am a patient (please complete the remainder of the questionnaire)

I am a caregiver of someone with this condition

I am a Healthcare Professional who takes care of patients with this condition

Other (please describe)

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* 2. What is your gender?

Female

Male

Other

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* 3. What is your age?

Less than 21

21-29

30-39

40-49

50-59

60-69

70+

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* 4. What is your ethnicity?

Hispanic

Black

Asian

Caucasian

Other (please specify)

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* 5. How were you diagnosed with Fatty Liver?

While being treated for another condition

Ask to be tested

Other (please specify)

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* 6. What health care professional diagnosed your liver condition?

Primary care physician

Gastroenterologist

Endocrinologist

Cardiologist

Other (please specify)

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* 7. How would you describe your present disease stage?

Fatty Liver

NASH

NASH with advance fibrosis

NASH Cirrhosis

Liver Cancer

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* 8. How would you rate your knowledge of your disease?

Excellent

Very good

Just okay

Insufficient

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* 9. In what areas would you want more information?

Nutrition

Physical activity

Disease progression

General liver information

Don’t need additional information

Other (please specify)

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* 10. Do you have any of the following conditions (check all that apply)?

Type 2 Diabetes

BMI > 25

High blood pressure

High levels of fat (triglycerides) in blood

Metabolic syndrome

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* 11. Do you belong to a patient support group?

Yes – local to me

Yes – virtual (please add name and location)

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* 12. Have you heard of the NASH kNOWledge Liver Support Group

Yes – I’m a member

Yes – Not a member

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* 13. Have you had a liver biopsy

Yes

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* 14. If you have had a liver biopsy, how many times?

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* 15. What types of non-invasive liver testing have you experienced (check all that apply)

Bloodwork

Fibroscan

MRI

Liver Multiscan

None

Other (please specify)

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* 16. Since your diagnosis of NAFLD, how successful do you believe you have been in making significant changes to your lifestyle habits (i.e., diet and physical activity)?

Extremely successful

Very successful

Moderately successful

Somewhat successful

Not successful

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* 17. Have you participated in a clinical trial for Fatty Liver/NASH?

Yes - please describe your experience

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* 18. Would you be willing to participate in a clinical trial for Fatty Liver/NASH?

Yes

Maybe

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* 19. Please describe your physical activity level

None

Moderate (2-3 times per week)

Advanced (4-7 times per week)

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* 20. How many sugar-sweetened beverages do you consume in an average week?

None

1-7

More than 7

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* 21. How many times do you eat fast food in an average week?

None

1-3

4-7

More than 7

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* 22. How many meals do you consume outside the home in an average week?

None

1-3

4-7

More than 7

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* 23. Do you follow a nutritional program?

Weight Watchers

Keto

Mediterranean

Other (please specify)

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* 24. What is your transplant status

Transplant is not something that has been discussed with me

Transplant has been discussed, but not contemplated right now

I am on the transplant waiting list

I am under consideration for transplant, but not yet on waiting list

I am post-transplant

NASH / NAFLD

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* 1. Why are you interested in Fatty Liver Disease

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* 2. What is your gender?

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* 3. What is your age?

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* 4. What is your ethnicity?

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* 5. How were you diagnosed with Fatty Liver?

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* 6. What health care professional diagnosed your liver condition?

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* 7. How would you describe your present disease stage?

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* 8. How would you rate your knowledge of your disease?

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* 9. In what areas would you want more information?

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* 10. Do you have any of the following conditions (check all that apply)?

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* 11. Do you belong to a patient support group?

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* 12. Have you heard of the NASH kNOWledge Liver Support Group

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* 13. Have you had a liver biopsy

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* 14. If you have had a liver biopsy, how many times?

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* 15. What types of non-invasive liver testing have you experienced (check all that apply)

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* 16. Since your diagnosis of NAFLD, how successful do you believe you have been in making significant changes to your lifestyle habits (i.e., diet and physical activity)?

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* 17. Have you participated in a clinical trial for Fatty Liver/NASH?

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* 18. Would you be willing to participate in a clinical trial for Fatty Liver/NASH?

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* 19. Please describe your physical activity level

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* 20. How many sugar-sweetened beverages do you consume in an average week?

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* 21. How many times do you eat fast food in an average week?

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* 22. How many meals do you consume outside the home in an average week?

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* 23. Do you follow a nutritional program?

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* 24. What is your transplant status

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* 25. Additional comments