Survey For Intake - Hope For CKD by ProKidney

Phone

This field is for validation purposes and should be left unchanged.

This field is hidden when viewing the form

About Proact 1 Study Pre-Screening Survey

This will be a pre-screening survey on the site that will allow us to filter through people who are not eligible and then we will forward those who have “passed” non-eligibility screener to the study sites for additional eligibility screening.

Informed Consent

Informed Consent means agreeing to let us use your personal details. By checking the box below, you agree to share your personal identifiable information (PII) with the PROACT 1 study team. Your information will only be used to see if you can join the study and find the best place for you to go based on where you live. Some communicable diseases such as HIV, are required to be reported to the state health department. “I consent” means you agree to something. By selecting the button, you agree to share your personal information with the PROACT 1 study team.

I consent to share my personal information with the PROACT 1 study team.(Required)

Yes

I consent to be contacted for future studies and to get educational information.(Required)

Yes

Demographic Information

Full Name(Required)

First Last

Email Address(Required)

Email Address Confirm Email Address

Phone Number(Required)

Mailing Address(Required)

Street Address Address Line 2 City State ZIP Code

Age:(Required)

Sex according to your reproductive organs and functions assigned at birth:(Required)

Male

Female

What is your racial/ethnic background (Select all that apply)?(Required)

White or Caucasian

Black or African American

Asian

American Indian or Alaska Native

Native Hawaiian or Other Pacific Islander

Latino or Hispanic

Health Questions

Please review the following conditions and select "Yes" if you have this condition, and "No" if you don't.

Do you have a history of Type 2 diabetes (body can't use insulin well)?(Required)

Yes

Do you have a history of kidney or other organ transplantation (organ replacement surgery)?(Required)

Yes

Do you have a history of advanced kidney disease?(Required)

Yes

Are you currently on dialysis?(Required)

Yes

Has your doctor told you that you will need dialysis in the next 18 months?(Required)

Yes

Are you under the care of a nephrologist?(Required)

Yes

Has your doctor told you that you will need a transplant within the next 2 years?(Required)

Yes

How far are you willing to travel to a study site? (Please select one):(Required)

Less than 10 Miles

10-20 Miles

20-30 Miles

More than 30 Miles

To another state

Do you need assistance with transportation to and from the clinic?(Required)

Yes

Unique ID

Thank You For Completing The Survey

Thank you for taking the time to complete our pre-screening survey. Your interest is greatly appreciated and helps us ensure the success of our study. If you have any questions or need further information, please visit www.hopeforckd.com Best regards, The PROACT 1 Research Team

Thank You For Completing The Survey

Thank you for taking the time to complete our pre-screening survey. Your interest is greatly appreciated and helps us ensure the success of our study. Unfortunately, you are not eligible for the PROACT 1 study. If you have any questions or need further information, please visit www.hopeforckd.com Best regards, The PROACT 1 Research Team

Thank You For Completing The Survey

Thank you for taking the time to complete our pre-screening survey. Your interest is greatly appreciated and helps us ensure the success of our study. Unfortunately, you are not eligible for the PROACT 1 study, but we will keep in touch to provide you with education about CKD and let you know about future studies as they come available. If you have any questions or need further information, please visit www.hopeforckd.com Best regards, The PROACT 1 Research Team Thank you for contacting us! We will get in touch with you shortly.

Welcome to the PROACT 1 Study Survey

About Proact 1 Study Pre-Screening Survey

Informed Consent

Demographic Information

Health Questions

Thank You For Completing The Survey

Thank You For Completing The Survey

Thank You For Completing The Survey

Learn how we helped 100 top brands gain success.

Let's have a chat