Request for Participation in a Questionnaire

medical record number		Age*	years
Date of Birth*	mm　dd　yyyy
Patient Name (Initials are acceptable)		Gender*	malefemaleN/A
Race
Disease	Renal hypouricemiaXanthinuria
Examination Date	mm dd yyyy
WBC	/μL	Ht	g/dL
Hb	g/dL	Plt	×10₄/μL
AST	IU/L	ALT	IU/L
γ-GTP	IU/L	TC	mg/dL
LDL	mg/dL	HDL	mg/dL
TP	g/dL	Alb	g/dL
BUN	mg/dL	Serum creatinine level	mg/dL
Serum uric acid level	mg/dL	HbA 1C	%
Ccr	mL/min	eGFR	mL/min
Urinalysis		Urinary protein
Urinary occult blood		Urinary sediment
RBC	/HPF	WBC	/HPF
Other abnormal findings

Urolithiasis	YesNo

If you selected "Yes", please enter the following information.

Date of diagnosis	mm dd yyyy
Disease site	Upper urethra lithiasisLower urethra lithiasisLeftRightBoth sides
Number of calculus
Component	CalciumDue to infectionUrateCystineXanthineOthersUnknown If you have any other comments or opinions about us, please describe in below form.

Exercise-induced acute kidney injury	YesNo

If you selected "Yes", please enter the following information.

Date of onset	mm dd yyyy
attachment	If you have any hospitalization summaries, please attach them after deleting personal information.
Symptoms	LumbagoNauseaEmesisFebriculaOthers Lumbago：Specifically Nausea：Symptoms： Emesis：Symptoms： Febricula：Symptoms： Others：Symptoms：
Serum creatinine level at initial examination	mg/dl	Most elevated serum creatinine level	mg/dl
Lowest Ccr (or eGFR)*	ml/min	Serum uric acid level at initial examination	mg/dl
Most elevated serum uric acid level	mg/dl	Duration of renal function decline	日
Urinary myoglobin level	ng/ml	Serum myoglobin level	ng/ml
Serum CPK level	U/l
Renal biopsy findings	Number of days from onset of renal injury to renal biopsy（）
Diagnostic Imaging	Number of days from onset of renal injury to examination（） Examination name　 Findings
Exercise as a cause of the onset
Duration of exercise	min	Hospitalization period	days
Serum creatinine level at discharge	mg/dl	Number of renal injury events	times
Complications (in illness)	Posterior reversible encephalopathy syndrome (PRES)Others times If you have any other comments or opinions about complication, please describe in below form.

Alzheimer dementia (Including suspected or mild cognitive impairment due to Alzheimer's disease).	YesNo

If you selected "Yes", please enter the following information.

Diagnostic criteria	DSM-5 criteriaNIA-AA criteriaIWG-2 criteria
Age at the onset	years old
Family history of Alzheimer's disease	NoYes If you selected "Yes" in th previous question, what are its etiologic genes? ）
Stage of Alzheimer's	EarlyMiddleLate
Symptoms	DysmnesiaDisorientationExecutive function disordersImpaired visuospatial abilityAllophasisDisability for daily livingPsychoneurosisOthers If you have any other comments or opinions about symptoms, please describe in below form.
Presence of factors influencing the onset/progression	Cerebrovascular disorderDiabetes mellitusHypertensionSmokingObesityDyslipidemiaHead traumaSleep apnea syndromeExercise regularlyOthers If you have any other comments or opinions about us, please describe in below form.

Cognitive function status	Mini Mental State Examination（ MMSE: points ） Montreal Cognitive Assessment-Japanese version（ MoCA-J: points ） Alzheimer’s Disease Assessment Scale cognitive subscale Japanese version（ ADAS-Jcog points ） Other criteria（ : points ）
Physical and mental status	Neuropsyciatric Inventory（ NPI: points ） Behavioral Pathology in Alzheimer’s Disease（ Behave-AD: points ） Other criteria（ : points ）
Daily living activity status	Physical Self-Maintenance Scale（ PSMS: points ） Instrumental Activities of Daily Living Scale（ IADL: points ） Alzheimer’s Disease Cooperative Study Activities of daily living inventory（ ADCS-ADL: points ） Other criteria（ : points ）
General disease severity	Clinical Dementia Rating（ CDR: points ） Other criteria（ : points ）
Diagnostic Imaging	Date（） Examination name（） Findings（）
Medications

Parkinson's disease、Hereditary or secondary Parkinson disease	YesNo

If you selected "Yes", please enter the following information.

Parkinson's diseaseHereditary Parkinson's diseaseSecondary Parkinson’s disease

If you selected "Parkinson's disease"　

If you selected "Hereditary Parkinson's disease"　

If you selected "Secondary Parkinson’s disease"　

Diagnostic criteria	Other criteriaMovement Disorder Society (MDS) criteria
Age at the onset	years old
Family history of Parkinson's disease	NoYes
Genetic mutation related to Parkinson's disease	NoYes If you selected "Yes", please enter the following information. ）
Severity classification	Hoehn-Yahr scale stage (Stage I, II, III, IV, V)Moter function (Stage I, II, III)
Medications

Amyotrophic lateral sclerosis	YesNo

If you selected "Yes", please enter the following information.

Diagnostic criteria	Awaji criteriaEl Escorial (Airlie House) criteria
Age at the onset	years old
Family history of ALS	NoYes If you selected "Yes", please enter the following information. ）
Severity classification	ALS Functional Rating Scale（ALSFRS-R score: ） Functional independence measure（FIM score: ）
Examinations	Forced vital capacity (%FVC) ％
Medications

Multiple sclerosis / Neuromyelitis optica	YesNo

If you selected "Yes", please enter the following information.

Diagnostic criteria	McDonald criteriaOther criteria
Disease form	Relapsing-remitting MS: RRMSSecondary progressive MS: SPMSPrimary progressive MS：PPMSNeuromyelitis Optica：NMONeuromyelitis optica spectrum disorder: NMOSD
Age at the onset	years old
Severity classification	Expanded Disability Status Scale of Kurtzke (EDSS score: ) Multiple Sclerosis Functional Composite (MSFC score: ） Multiple Sclerosis Severity Score (MSS score: ） Other（ :　score: ）
Examinations (Anti-AQP4 antibody, MRI, et cetera.)	Date（） Examination name（） Findings（）
Medications

Consent to the Privacy Policy*	I agree to the Privacy Policy.

Hypouricemia