Nephrogenic Systemic Fibrosis and Nephrogenic Fibrosing Dermopathy (NSF/NFD) is a rare boutique disease

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Gadolinium Case Questionnaire

First Name:

Last Name:

Address:

City:

State:

Zipcode:

Phone:

() - ext.

Work Phone:

() - ext.

Mobile Phone:

() - ext.

E-mail Address:

Have you been diagnosed with NSF (nephrogenic systemic fibrosis) or
NFD (nephrogenic fibrosing dermopathy)?

Yes
No

When and where was the diagnosis made?

When did your problems start?

Describe your symptoms and how they developed.

Did you have an MRI (magnetic resonance imaging) or MRA (magnetic resonance angiography) scan done before your symptoms began?

Yes
No

Where and when was the scan (or were the scans if more than one) done?

Did you have kidney failure, kidney function deficiency, or other kidney problems at the time the scan (or scans) were done?

Yes
No

Describe the kidney problems you had.

Please provide any additional information, comments or questions: