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Bahamas Kidney Association
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Email
*
Your email
Name
*
Your answer
Date of birth
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MM
/
DD
/
YYYY
Gender
*
Male
Female
Martial status
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Single
Married
Divorced
Widow
Address
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Your answer
Island
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Your answer
Ethnicity
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Black
Caucasian
Other
Are you employed?
*
Yes
No
Do you have kidney disease
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Yes
No
Other:
How long have you had kidney disease? (If this does not apply please response N/A)
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Your answer
Are you on dialysis?
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Yes
No
How long have you been on dialysis?
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Your answer
Was your kidney failure a result of
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Diabetes
Hypertension
Diabetes & Hypertension
Polycystic
Other:
Name of medical provider
*
Your answer
Do you have any disabilities?
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No
Yes
Do you have any dependents
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Yes
No
How many?
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Your answer
Do you have medical insurance?
*
Yes
No
How did you hear about us?
*
Medical provider
A family/friend
Social Media
Other:
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