APOL1 Mediated Kidney Disease Study Survey

Please complete this short survey to see if you qualify to participate in this study.

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* 1. Please leave your name, phone number, and email for us to contact you should you qualify for this trial.

Name:

Phone #:

Email:

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* 2. Are you or the person you are completing this survey for at least 10 years old?

Yes

No

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* 3. Are you or the person you are completing this survey for 65 years old or younger?

Yes

No

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* 4. Is there a history of kidney disease in your family?

Yes

No

I don't know

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* 5. Have you ever been told you have kidney disease?

Yes

No

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* 6. Have you ever been diagnosed with diabetes?

Yes

No

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* 7. Have you ever been diagnosed with lupus nephritis, sickle cell disease, or diabetic kidney disease?

Yes

No