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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.

By continuing, you agree to the privacy policy,
and you consent to the use and disclosure of your
personal information as described in the privacy policy.

1. Are you between the ages of 12 and 70 years old?

2. Have you been diagnosed with (or are you suspected of having) Alport syndrome or related diagnoses such as thin basement membrane nephropathy, hematuria-nephropathy deafness, hemorrhagic familial nephritis, hereditary deafness and nephropathy, hereditary nephritis, hereditary nephritis with sensory deafness, etc.

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

15. Please provide your contact information so that we can reach out in the instance you qualify for an in-person Screening visit. As a reminder, your information will not be used for other purposes.