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For the general public

Questionnaire

Basic Information

Your Name (Initials are acceptable)
Gender*
Date of Birth*mm　dd　yyyy
Address
Phone number
e-mail adress*
(Reenter your email address to confirm.)
Nationality*
Cause of Hypouricemia*
Would you like medical check-up?*
Height / cm*cmWeight / kg*Kg
Weight at 20 years old / kg*kgWeight at peak / kg*Kg

Alcoholic Habits

*How many days per week do you drink alcoholic beverages (beer, whiskey, wine, sake, shochu, etc.)?（Please choose one.）

The following questions are for persons who selected any of the answers from [3] to [6].

*What is the main alcoholic beverage you drink?

【6】Others, please be specific　

*On days when you drink alcohol, how much do you drink per day in terms of pure alcohol? (Please choose one) *Amount of alcoholic beverage (mL) x % / 100 x 0.8 = pure alcohol (g)

*Weekly average

Number of times to drink per week　
Drinking amount per time　 with g

Smoking Habits

*Do you smoke?

【2】This is a question for persons who answered that they smoke.
Number of cigarettes smoked per day* /day
Number of years of smoking　 years

Exercise Habits

*Exercise Habits (複数回答可)

For those who have selected one of 【4】 to 【6】

*Please describe the content of the exercise.

Medical History

*Please list any illnesses you have had and are currently being treated for.

Disease name*
Age at the onset.* years
Please choose one.*

【3】Add more　

Disease name*
Age at the onset.* years
Please choose one.*

【3】Others, please be specific　

Disease name*
Age at the onset.* years
Please choose one.*

【3】Others, please be specific　

Disease name*
Age at the onset.* years
Please choose one.*

【3】Others, please be specific　

Disease name*
Age at the onset.* years
Please choose one.*

【3】Others, please be specific　

Disease name*
Age at the onset.* years
Please choose one.*

【3】Others, please be specific　


*Are you currently taking any medications? (If not, write N/A.)

Name of the medicine.*
How much do you take per day?*
How long have you been taking it?*

Name of the medicine.*
How much do you take per day?*
How long have you been taking it?*

Name of the medicine.*
How much do you take per day?*
How long have you been taking it?*

Name of the medicine.*
How much do you take per day?*
How long have you been taking it?*

Name of the medicine.*
How much do you take per day?*
How long have you been taking it?*

Name of the medicine.*
How much do you take per day?*
How long have you been taking it?*

We may need to know more about your medical history and complications.

*Can we ask your doctor to fill out a questionnaire about your disease?

【1】 If you select Yes, please enter the contact information of your doctor.

*Contact information for your doctor

*After a while, could you please fill out the questionnaire again so that we can know the progress?

同意*

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