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Pre-Screener
Pre-Screener

Inquiry Form

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Eligibility Pre-Screener

To see if you may qualify for participation in CARDINAL, please answer the following questions to the best
of your ability. This should take approximately 5 minutes. The information you provide will be used ONLY
for the purpose of determining your potential eligibility for the study. It will not be sold, shared or
transferred to any party not directly involved in CARDINAL. At the completion of the study
(approximately December of 2019), your information will be destroyed.

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1. Are you between the ages of 12 and 60 years old?

2. Have you been diagnosed with (or are you suspected of having) Alport syndrome?

3. Are you currently pregnant or breastfeeding?

4. Have you had a renal transplant?

5. Are you currently being treated with hemodialysis or peritoneal dialysis?

6. Has your doctor told you that you have heart failure and/or heart diseases of your valves and/or diseases of the sac surrounding the heart?

7. Have you been diagnosed with coronary artery disease (disease of the heart vessels)?

8. Have you ever been hospitalized for heart failure?

9. Have you been diagnosed with cancer, other than skin or cancer of the cervix, within the last 5 years?

10. Have you ever taken bardoxolone methyl, an investigational drug for the treatment of various diseases such as pulmonary hypertension, kidney disease, etc.?

11. Have you ever been on acute dialysis?

12. Has a doctor ever told you that you've had an acute kidney injuriy?

13. Please provide the name of the doctor currently treating your Alport syndrome. If you are unsure, please leave blank.

14. Please tell us how you heard about CARDINAL.

Alport Syndrome Foundation

ASTOR Registry

BioNews Website / Newsletter

Web Ads or Google Searches

My Physician

Other