Tell us your Chronic Kidney Diseases story
Have you been diagnosed with Chronic Kidney Diseases? (Optional)
Select One
Yes
No
Not Sure
Not Applicable
Does Chronic Kidney Diseases impact relationships with family or caregivers? (Optional)
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Yes
Somewhat
No
Not Sure
Not Applicable
Does Chronic Kidney Diseases impact your daily exercise or other activities? (Optional)
Select One
Yes
Somewhat
No
Not Sure
Not Applicable
Does Chronic Kidney Diseases impact your mental health? (Optional)
Select One
Yes
Somewhat
No
Not Sure
Not Applicable
Does Chronic Kidney Diseases impact your healthcare costs? (Optional)
Select One
Yes
Somewhat
No
Not Sure
Not Applicable
Are you currently looking for a Chronic Kidney Diseases clinical trial? (Optional)
Select One
Yes
No
Not Sure
Not Applicable
First Name
Last Name
Email
Phone (Optional)
Age (Optional)
Postal Code (Optional)
Gender (Optional)
Select One
Male
Female
Transgender Male
Transgender Female
Gender Variant/Non-Conforming
Unspecified
How would you like to be contacted? (Optional)
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Phone Call
SMS
Text
Any
What would you like researchers to know about your experience with Chronic Kidney Diseases? (Optional)
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