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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*
E-mail Address*
City*
State/Prov*
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

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Gout Questionnaire


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