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APOL1 Mediated Kidney Disease Study Survey
Please complete this short survey to see if you qualify to participate in this study.
1.
Please leave your name, phone number, and email for us to contact you should you qualify for this trial.
Name:
Phone #:
Email:
2.
Are you or the person you are completing this survey for at least 10 years old?
Yes
No
3.
Are you or the person you are completing this survey for 65 years old or younger?
Yes
No
4.
Is there a history of kidney disease in your family?
Yes
No
I don't know
5.
Have you ever been told you have kidney disease?
Yes
No
6.
Have you ever been diagnosed with diabetes?
Yes
No
7.
Have you ever been diagnosed with lupus nephritis, sickle cell disease, or diabetic kidney disease?
Yes
No