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Gout Questionnaire

Gout Aware's Gout Questionnaire

was designed to allow other readers of the site to compare how they fare in their suffering of Gout.

The questions summarize up a basic lifestyle and family history to link individuals into a commonality of reasons why we each have Gout.

Each time you finish the Questionnaire the results will be displayed instantly to compare how you fare in certain areas.

Over time I hope to have hundreds if not thousands of people answering the Questionnaire to give a larger more accurate perspective.

In the future I will make a more integrated more in-depth questionnaire.

It will only take aminute of so to complete.

Thank you for your time.

Your email address will not be sold or given away. It will be completely secure.

regards

Peter

admin@gout-aware.com

Gout Questionnaire

Please note that all fields followed by an asterisk must be filled in.

First Name*
First Name*

E-mail Address*
E-mail Address*

City*
City*

State/Prov*
State/Prov*

Country*
Country*

Are you overweight?

	YES
	NO
	MY WEIGHT VARIES

Do you Drink alcohol?

	YES
	NO
	SOMETIMES

Do you drink large amounts of alcohol?

	YES
	NO
	SOMETIMES
	I BINGE DRINK

Which type of Alcohol do you drink?

	BEER
	WINE
	SPIRITS
	ALL OF THE ABOVE

Have you had surgery recently and have gout?

	YES
	NO
	DON'T KNOW

Do you take Diuretics?

	YES
	NO
	SOMETIMES

Do you suffer from High Blood Pressure?

	YES
	NO
	SOMETIMES

Is there Gout in your family medical history?

	YES
	NO
	DON'T KNOW

Which of your family members suffer from Gout?

	FATHER
	MOTHER
	BROTHER
	SISTER
	UNCLE
	AUNT
	GRANDPARENTS
	NONE

Do you have a history of Kidney Stones?

	YES
	NO
	NOT SURE

Has anyone else in your family had Kidney stones?

	YES
	NO
	NOT SURE

How long did your last Gout attack last for?

	1 DAY
	2 TO 4 DAYS
	1 WEEK
	MORE

Do you Diet regularly?

	YES
	NO
	SOMETIMES

Have you had a dramatic loss of weight then had a Gout attack?

	YES
	NO
	OCCASIONALLY
	CAN'T REMEMBER

When you get a Gout attack, where do you get it?

	BIG TOES
	HEELS
	ANKLES
	ELBOWS
	FEET
	HAND
	WRISTS
	FINGERS
	KNEES
	BACK
	NECK
	OTHER

What is your age?

	BETWEEN 20 - 30
	BETWEEN 30 - 40
	BETWEEN 40 - 50
	BETWEEN 50 - 60
	BETWEEN 60 - 70
	BETWEEN 70 - 80
	BETWEEN 80 - 90

Do you have other Health Issues?

	YES
	NO
	NOT REALLY

Have you suffered side effects from Gout medicine?

	YES
	NO
	NOT SURE

What non-medical remedies do you take to control your Gout?

	APPLE CIDER VINEGAR
	BAKING SODA
	WATER
	CHERRIES OR CHERRY JUICE
	IONIZED/ALKALINE WATER
	LOW URIC ACID DIET
	CELERY EXTRACTS
	ALFALFA
	HERBAL TEAS
	VITAMINS
	OTHER HERBS
	NOTHING

What Gout Medicine do you take?

	NSAIDs
	ANALGESICS
	CORTICOSTEROIDS
	DMARDs
	BIOLOGIC DRUGS
	OTHER

What is your Gender?

	MALE
	FEMALE

Please enter the word that you see below.

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E-mail Address* E-mail Address*
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Gout Questionnaire

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