MyDiabetesTrial



		
	






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Patient Pre-Screener

To see if you might qualify for this clinical trial and to be referred to the local trial center in your area, please take a moment to complete the questionnaire below.

There’s No Obligation

Completing the questionnaire does NOT obligate you to participate in the trial. Your answers help determine if you are a candidate for the trial. If you pass the online pre-screener you may be contacted, with your permission, by a local trial coordinator or a trial representative. Representatives may contact you by telephone, email or text. Message and data rates may apply.

1) Have you been diagnosed with Polycystic Kidney Disease (PKD) by a physician?

Yes, it is Autosomal Dominant Kidney Disease (ADPKD)

Yes, it is infantile or Autosomal Recessive Kidney Disease (ARPKD)

Yes, it is Acquired Cystic Kidney Disease (ACKD)

Yes, but I don't know which type of PKD I have

No

This is a required question. Please double-check your answer and resubmit.

2) What is your year of birth?

This is a required question. Please double-check your answer and resubmit.

3) Are you currently taking Tolvaptan (e.g. Jynarque™, SAMSCA®)?

Yes, I am taking Tolvaptan, and I am happy with my current treatment

Yes, I am taking Tolvaptan, but I am not happy with my current treatment

No, I am not taking Tolvaptan

I'm not sure

This is a required question. Please double-check your answer and resubmit.

4) If you have had your estimated glomerular filtration rate (eGFR) levels tested, what was the result?

Less than 45 mL/min/1.73 m2

Between 45-90 mL/min/1.73 m2

Greater than 90 mL/min/1.73 m2

I'm not sure

I have not had my eGFR levels tested.

This is a required question. Please double-check your answer and resubmit.

5) Do any of the following apply to you? (Check all that apply.)

Currently pregnant or planning to become pregnant in the next 2 years

Currently breast-feeding

Diagnosed with HIV

Diagnosed with Hepatitis B or C

Currently have a malignancy or have had one within the past 5 years

Currently have cancer other than non-malignant skin cancer

Currently being treated for severe depression

Currently scheduled for surgery in the next 2 years

Currently participating in another clinical trial

None of the above

This is a required question. Please double-check your answer and resubmit.

6) What is your ZIP Code?

This is a required question. Please double-check your answer and resubmit.

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