Full Name

Address

City, State & Zip Code

Sex Age

Home Phone Work Phone Mobile Phone

EMail Address

1. Have you been diagnosed with NSF (nephrogenic systemic fibrosis) or NFD (nephrogenic fibrosing dermopathy)? YES NO

2. If you answered yes to #1:

a. When and where was the diagnosis made?

b. When did your problems start?

c. Describe your symptoms and how they developed.

3. If you answered no to #1, describe the symptoms or problems you have.

4. Did you have an MRI (magnetic resonance imaging) or MRA (magnetic resonance angiography) scan done before your symptoms began? YES NO

(If no, go to question #7)

5. If you answered yes to #4:

a. Where and when was the scan or scans done?

b. Did you have kidney failure, kidney function deficiency, or other kidney problems at the time the scan or scans were done? YES NO

(If no, go to question #8)

6. If yes to 5b, describe the kidney problems you had.

7. If no to #4, why do you think you might have a gadolinium claim? (there is no case without an MRI or MRA, because there is no other way to get gadolinium into the body)

8. If you answered no to #5b, do you have any reason to think that your kidneys were not functioning properly when you had the scan or scans?. If so, please explain.

If the person has NSF/NFD or the description is consistent with this diagnosis, but the person doesn't know of any kidney failure or kidney insufficiency, the person might have, or might have had, a kidney problem and not know it. Do not give up on a cliam if there was MRI or MRA, and symptoms consistent with NSF/NFD began afterward, even if there is no apparent kidney problem.

9. Is there anything else you would like to tell us?