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Health Study- P250807

Please provide us with your First and Last Name

*

Please provide us with your email address.

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With which of the following conditions, if any, have you been formally diagnosed by a doctor? (Please select all that apply)

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With which of the following conditions, if any, have you been formally diagnosed by a doctor? (Please select all that apply)

A

Atrial Fibrillation

B

Chronic heart Failure

C

Coronary Artery Disease

D

Chronic Kidney Disease

E

Type 1 Diabetes

F

Type 2 Diabetes

G

I have not been formally diagnosed by a doctor with any condition

H

Other

At which stage is your CKD, as formally diagnosed by your doctor?

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At which stage is your CKD, as formally diagnosed by your doctor?

A

Stage 1- Mild kidney damage (eGFR ≥ 90)

B

Stage 2- Mild kidney damage (eGFR 60 - 89)

C

Stage 3a- Mild to moderate kidney damage (eGFR 45 - 59)

D

Stage 3b- Moderate to severe kidney damage (eGFR 30 - 44)

E

Stage 4- Severe kidney damage (eGFR 15- 29)

F

Stage 5- Kidney Failure (eGFR < 15)

G

I’m not sure

Which type of health insurance do you currently have?

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Which type of health insurance do you currently have?

A

Private insurance from an employer or that you purchase on your own (i.e. PPO, HMO plan)

B

Medicare

C

Medicaid

D

Uninsured

E

Other