Kidney and Urinary Disorders Questionnaire

PLEASE STATE THE PRECISE DIAGNOSIS (IF KNOWN):

DATE OF DIAGNOSIS:

HAVE YOU HAD AN IVP, CYSTOSCOPY OR OTHER INVESTIGATIONS?

Yes No

IF YES, PLEASE PROVIDE DETAILS INCLUDING DATE(S) OF INVESTIGATIONS AND RESULTS:

RECENT CREATININE READING:

REGARDING YOUR SYMPTOMS:

A.) PLEASE DESCRIBE YOUR SYMPTOMS:

B.) WHEN DID SYMPTOMS FIRST OCCUR?

C.) HOW OFTEN HAVE YOUR SYMPTOMS OCCURRED WITHIN THE LAST 12 MONTHS?

D.) WHEN WAS THE LAST OCCURRENCE OF SYMPTOMS?

HAVE YOU HAD AN OPERATION FOR THIS CONDITION OR IS AN OPERATION BEING CONSIDERED?

Yes No

IF YES, PLEASE PROVIDE DETAILS INCLUDING DATE(S), HOSPITAL AND CONSULTANT/SURGEON:

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