Specify if the patient has ever had any of the following conditions:
Kidney problems, including dialysis? – Select Yes or No.
With Yes selected, a set of responses (Date and Description) is available.
For each additional set of responses you want to add, click Add More. You can add up to four additional sets of responses.
Note: To delete an additional set of responses, click the corresponding Delete button 
.
Optionally, select a year and/or description for each set of responses:
Date - Select a year or Unknown. If a year is selected, to specify that the year is approximate, select the Approximate Date checkbox.
Description - Select one of the following descriptions:
Chronic Kidney Disease: Stage 1.
Chronic Kidney Disease: Stage 2.
Chronic Kidney Disease: Stage 3.
Chronic Kidney Disease: Stage 4.
Dialysis: Hemodialysis.
Dialysis: Periodontal Dialysis.
Kidney Transplant.
Polycystic Kidney Disease (PKD).
Glomerulonephritis.
Kidney Cancer.
Fabry Disease.
Alport Syndrome.
Focal Segmental Glomerulosclerosis (FSGS).
Other – With this option selected, an Add description box is available. Optionally, enter up to 60 characters.
Hepatitis? If so, what type and is it currently active? – Select Yes or No.
With Yes selected, a set of responses (Date and Description, and Active Status) is available.
For each additional set of responses you want to add, click Add More. You can add up to four additional sets of responses.
Note: To delete an additional set of responses, click the corresponding Delete button .
Optionally, select a year, description, and/or active status for each set of responses:
Date - Select a year or Unknown. If a year is selected, to specify that the year is approximate, select the Approximate Date checkbox.
Description - Select one of the following descriptions:
Hepatitis: A.
Hepatitis: B.
Hepatitis: C.
Hepatitis: D.
Hepatitis: E.
Hepatitis: Autoimmune.
Other – With this option selected, an Add description box is available. Optionally, enter up to 60 characters.
Active Status - Select one of the following active statuses:
Active: Yes.
Active: No.
Active: In Treatment.
Do you have any type of liver condition? – Select Yes or No.
With Yes selected, a set of responses (Date and Description) is available.
For each additional set of responses you want to add, click Add More. You can add up to four additional sets of responses.
Note: To delete an additional set of responses, click the corresponding Delete button .
Optionally, select a year and/or description for each set of responses:
Date - Select a year or Unknown. If a year is selected, to specify that the year is approximate, select the Approximate Date checkbox.
Description - Select one of the following descriptions:
Fatty Liver Disease.
Fibrosis.
Cirrhosis.
Liver Cancer.
Hemochromatosis.
Alcohol Related Liver Disease.
Alpha-1 Antitrypsin Deficiency.
Budd-Chiari Syndrome.
Gilbert Syndrome.
Type 1 Glycogen Storage Disease (GSD 1).
Hepatorenal Syndrome (HRS).
Wilson Disease.
Liver Transplant.
Other – With this option selected, an Add description box is available. Optionally, enter up to 60 characters.