Kidney Stone Symptoms Questionnaire
Please answer the following questions to help assess your symptoms related to kidney stones. Your responses are confidential and used only for assessment purposes.
What is your age?
*
What is your sex assigned at birth?
*
Male
Female
Prefer not to say
When did your symptoms begin?
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Where do you feel the pain most?
*
Lower back
Side (flank)
Lower abdomen/groin
Other location
How would you rate your pain?
*
No pain
0
1
2
3
4
5
6
7
8
9
Worst pain imaginable
10
0 is No pain, 10 is Worst pain imaginable
Have you noticed any of the following symptoms? (Select all that apply)
*
Blood in urine
Frequent urination
Painful urination
Nausea or vomiting
Fever or chills
None of the above
Have you had kidney stones before?
*
Yes
No
Not sure
Do you have any of the following medical conditions? (Select all that apply)
Diabetes
High blood pressure
Urinary tract infection
None of the above
Are you currently taking any medications? (If yes, please list them)
Is there anything else you would like to share about your symptoms?
Submit
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