+-------------------------------+--------------------------------------+
| **FIND Medical                |                                      |
| Questionnaire**               |                                      |
+-------------------------------+--------------------------------------+
| **Barcode and**               | Study Coordinator ID                 |
|                               | \_\_\_\_\_­­­­­\_\_\_\_\_\_\_\_\_\_       |
| **Participant ID**            |                                      |
|                               | Date of interview (*MM/DD/YYYY*)     |
|                               | \_\_ \_\_ \| \_\_ \_\_ \| \_\_ \_\_  |
|                               | \_\_ \_\_                            |
+-------------------------------+--------------------------------------+

The informant is:

Participant Proxy

If **Proxy**, give name and relationship to the participant:

Enrolled In (Select All that Apply)

 Family Study  AA MALD Diabetic  AA MALD Non-Diabetic  MA MALD

 Hypernormal Control

If Female, are you pregnant?

No Yes Don't Know

If **No**, complete the entire form.

If **Yes,** record the estimated date of delivery (MM/DD/YYYY): \_\_
\_\_/\_\_ \_\_/\_\_ \_\_ \_\_ \_\_, collect the data in Section A only,
and complete the interview and sample collection when the participant is
at least six weeks post partum.

If **Don't Know**, perform a urine pregnancy test. If the test is
negative, complete the entire form. If the test is positive collect the
data in Section A only and complete the interview and sample collection
when the participant is at least six weeks post partum.

A. PARTICIPANT INFORMATION

1.  **Name**:

> *Last First Middle Maiden*

2.  **Address**:

> *Street or Descriptive Address (for those without a street address)
> Apt City*
>
> *State/Province Postal code Country*

3.  **Telephone**: Home \_\_ \_\_ \_\_ - \_\_ \_\_ \_\_ - \_\_ \_\_ \_\_
    \_\_ Work \_\_ \_\_ \_\_ - \_\_ \_\_ \_\_ - \_\_ \_\_ \_\_ \_\_

> **or** if outside the U.S.:
>
> Country code \_\_ \_\_ \_\_ Home \_\_ \_\_ \_\_ \_\_ \_\_ \_\_ \_\_
> \_\_ \_\_ \_\_ Work \_\_ \_\_ \_\_ \_\_ \_\_ \_\_ \_\_ \_\_ \_\_ \_\_

4.  **Cell phone**: \_\_ \_\_ \_\_ - \_\_ \_\_ \_\_ - \_\_ \_\_ \_\_
    \_\_

5.  **Pager**: \_\_ \_\_ \_\_ - \_\_ \_\_ \_\_ - \_\_ \_\_ \_\_ \_\_

6.  **Fax**: \_\_ \_\_ \_\_ - \_\_ \_\_ \_\_ - \_\_ \_\_ \_\_ \_\_

7.  **E-mail**:

8.  **Number range level0Number range level1Number range level2Number
    range level3Number range level4Number range level5Number range
    level6Number range level7Birth date** (*MM/DD/YYYY*): \_\_ \_\_ \|
    \_\_ \_\_ \| \_\_ \_\_ \_\_ \_\_

9.  **Social Security Number**: \_\_ \_\_ \_\_ - \_\_ \_\_ - \_\_ \_\_
    \_\_ \_\_

10. **Sex**: Male Female

11. **Ethnicity**: African American American Indian; tribal identifier
    \_\_

European American Mexican American Other Hispanic
Other\_\_\_\_\_\_\_\_\_\_\_\_\_

12. **Country of birth**: **City of
    Birth**:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

    13. **Name of your primary doctor**:

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**OR** if outside the U.S.

Telephone: \_\_ \_\_ \_\_ - \_\_ \_\_ \_\_ - \_\_ \_\_ \_\_ \_\_ Country
code \_\_ \_\_ \_\_ Tel \_\_ \_\_ \_\_ \_\_ \_\_ \_\_ \_\_ \_\_ \_\_
\_\_

> Location:
>
> *Street Suite City*
>
> *State/Province Postal code Country*

14. **Name of your dialysis or transplant unit**:

**OR** if outside the U.S.

Telephone: \_\_ \_\_ \_\_ - \_\_ \_\_ \_\_ - \_\_ \_\_ \_\_ \_\_ Country
code \_\_ \_\_ \_\_ Tel \_\_ \_\_ \_\_ \_\_ \_\_ \_\_ \_\_ \_\_ \_\_
\_\_

> Location:
>
> *Street Suite City*
>
> *State/Province Postal code Country*

15. **Name of your nephrologist**:
    \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**OR** if outside the U.S.

Telephone: \_\_ \_\_ \_\_ - \_\_ \_\_ \_\_ - \_\_ \_\_ \_\_ \_\_ Country
code \_\_ \_\_ \_\_ Tel \_\_ \_\_ \_\_ \_\_ \_\_ \_\_ \_\_ \_\_ \_\_
\_\_

> Location:
>
> *Street Suite City*
>
> *State/Province Postal code Country*

16. **Name of your eye doctor**:
    \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**OR** if outside the U.S.

Telephone: \_\_ \_\_ \_\_ - \_\_ \_\_ \_\_ - \_\_ \_\_ \_\_ \_\_ Country
code \_\_ \_\_ \_\_ Tel \_\_ \_\_ \_\_ \_\_ \_\_ \_\_ \_\_ \_\_ \_\_
\_\_

> Location:
>
> *Street Suite City*
>
> *State/Province Postal code Country*

+-----------------------------------------------------------------------+
| **Barcode and**                                                       |
|                                                                       |
| **Participant ID**                                                    |
+-----------------------------------------------------------------------+

17. **Are you currently participating in another study**?

No Yes

If yes, please
specify:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

B. HEIGHT AND WEIGHT

18. **Current height and weight**: (ft) \_\_ (*in*) \_\_ \_\_ (cm) \_\_
    \_\_ \_\_ (weight lbs) \_\_ \_\_ \_\_ (kilos) \_\_ \_\_ \_\_

19. **Maximum weight or dry weight** (*lbs*.): \_\_ \_\_ \_\_ (kilos)
    \_\_ \_\_ \_\_

20. **Age and height at maximum weight**: (*years*) \_\_ \_\_ (*ft*)
    \_\_ (*in*) \_\_ \_\_ (cm) \_\_ \_\_ \_\_

21. **Have you ever had a major leg amputation (*above the ankle*)**?

No Yes

If **Yes**, specify locations (*Mark all that apply*): Left below the
knee Right below the knee

Left above the knee Right above the knee

C. KIDNEY DISEASE

22. **Do you have high blood pressure**?

No Yes Don't know

If **Yes**, when was your high blood pressure diagnosed (*year*)?

23. **Have you ever had a kidney biopsy**?

No Yes  Don't know

If **Yes**, when did you have the kidney biopsy (*year*)?

Where was the kidney biopsy performed?

24. **Do you have kidney failure requiring dialysis or transplant**?

> No Yes
>
> If **Yes**, indicate the date of onset of dialysis treatment
> (*MM/DD/YYYY*): \_\_ \_\_ \| \_\_ \_\_ \| \_\_ \_\_ \_\_ \_\_
>
> If **No**, skip to section D.

25. **Have you ever had an organ transplant?**

> No Yes Please Specify\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

26. **What caused your kidney failure/renal insufficiency (*Mark all
    that apply*)**?

Diabetes Polycystic kidney disease

Hypertension Lupus nephritis

IgA nephropathy Kidney cancer

 Membranous glomerulonephritis Obstruction

Focal glomerulosclerosis Don't know

> Other None

D. HISTORY OF DIABETES

27. **Has a doctor or other health care provider told you that you had
    diabete**s?

No  Yes Don't know

> If **Yes**, at what age were you diagnosed? \_\_ \_\_ **OR** in what
> year were you diagnosed? \_\_ \_\_ \_\_ \_\_

+-----------------------------------------------------------------------+
| **Barcode and**                                                       |
|                                                                       |
| **Participant ID**                                                    |
+-----------------------------------------------------------------------+

28. **Have you ever been treated for diabetic ketoacidosis or coma**?

> No Yes Don't know

29. **Have you ever taken insulin shots to treat your diabetes**?

> No Yes Don't know
>
> If **Yes**, how soon after diagnosis did you first begin taking
> insulin?
>
>  Within 1 year At least 1 year after diagnosis
>
> Once you started taking insulin shots, did you ever go at least one
> month without insulin treatment?
>
> No Yes Don't know

E. DIABETIC EYE DISEASE

30. **Have you ever had laser treatment of your retina(s) done for
    diabetes**?

 No Yes Don't know

31. **Have you ever been treated for bleeding inside your eye that was
    not due to trauma**?

No Yes Don't know

32. **Have you ever seen an ophthalmologist or optometrist (eye
    doctor)?**

> No Yes Don't know

*Continued on Next Page*

+-----------------------------------------------------------------------+
| **Barcode and**                                                       |
|                                                                       |
| **Participant ID**                                                    |
+-----------------------------------------------------------------------+

F. CURRENT MEDICINES

32. **Are you controlling diabetes through diet or lifestyle
    modification?**

> No Yes Don't know

33. **Are you taking any medicines (*including all over-the-counter and
    prescription pills, skin patches, eye drops, and injections*)**?

No Yes Don't know

> If **Yes** and you **do not** have kidney failure (dialysis or
> transplant), please record all current medicines.

  -----------------------------------------------------------------------------------------------------------------------------------------------------
  Drug Name                                                                  
  -------------------------------------------------------------------------- --------------------------------------------------------------------------
  \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_   \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

  \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_   \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

  \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_   \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

  \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_   \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

  \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_   \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

  \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_   \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

  \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_   \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

  \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_   \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

  \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_   \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

  \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_   \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

  \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_   \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

  \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_   \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

  \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_   \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

  \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_   \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

  \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_   \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

  \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_   \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

  \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_   \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

  \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_   \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
  -----------------------------------------------------------------------------------------------------------------------------------------------------

Note: If there are more current medicines than fit on this page, attach
an additional copy of this page.

**Family Investigation of Nephropathy and Diabetes (FIND)**

> **Family Pedigree Form**

**Date**: \_\_\_\_\_\_\_/\_\_\_\_\_\_\_/\_\_\_\_\_\_\_\_

Screened by:

+---------------+------------------------------------------------------+
| **Name: Last, |                                                      |
| First, MI**   |                                                      |
+---------------+------------------------------------------------------+
| **Address:**  |                                                      |
+---------------+------------------------------------------------------+
| **Telephone   | ( )-                                                 |
| number:**     |                                                      |
+---------------+------------------------------------------------------+
| **Cl          |                                                      |
| inic/Dialysis |                                                      |
| Unit**        |                                                      |
|               |                                                      |
| **Contact     |                                                      |
| physician**   |                                                      |
|               |                                                      |
| *             |                                                      |
| *City/State** |                                                      |
+---------------+------------------------------------------------------+

**Language preference (please circle): 1) English (2) Spanish (3)Other
(specify)\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**1. Date of Birth:** \_\_\_\_\_\_\_\_ **2. Gender:** [ٱ]{dir="rtl"}
Male **3. Ethnicity:** [ٱ]{dir="rtl"} African-American [ٱ]{dir="rtl"}
Female *Mark all that* [ٱ]{dir="rtl"} European-American

*Apply* [ٱ]{dir="rtl"} Mexican-American

[ٱ]{dir="rtl"} Other Hispanic (please, specify)\_\_\_\_\_\_\_\_

[ٱ]{dir="rtl"} Native American

> [ٱ]{dir="rtl"} Other (please, specify)\_\_\_\_\_\_\_\_

**4. Do you have any living, blood related relatives with diabetes
(siblings/parents)?**

[ٱ]{dir="rtl"} No, I am not aware of relatives having diabetes.

[ٱ]{dir="rtl"} I do not know, I am not sure.

[ٱ]{dir="rtl"} **Yes,** I have relatives with diabetes.

**[If YES obtain consent to get family information and continue with
Table #1]{.underline}**

**Table 1 -- Grandparent Pedigree**

Screening for the FIND Study

+-------------+-------------+-------------+-------------+-------------+
|             | **Maternal  | **Maternal  | **Paternal  | **Paternal  |
|             | Gr          | Gr          | Gr          | Gr          |
|             | andmother** | andfather** | andmother** | andfather** |
+-------------+-------------+-------------+-------------+-------------+
| Last Name   |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+
| First Name  |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+
| Middle      |             |             |             |             |
| Initial     |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+
| Birth Date  |             |             |             |             |
+-------------+-------------+-------------+-------------+-------------+
| Ethnicity   | [ٱ]         | [ٱ]         | [ٱ]         | [ٱ]         |
|             | {dir="rtl"} | {dir="rtl"} | {dir="rtl"} | {dir="rtl"} |
| Check all   | Afric       | Afric       | Afric       | Afric       |
| that apply  | an-American | an-American | an-American | an-American |
|             |             |             |             |             |
|             | [ٱ]         | [ٱ]         | [ٱ]         | [ٱ]         |
|             | {dir="rtl"} | {dir="rtl"} | {dir="rtl"} | {dir="rtl"} |
|             | Europe      | Europe      | Europe      | Europe      |
|             | an-American | an-American | an-American | an-American |
|             |             |             |             |             |
|             | [ٱ]         | [ٱ]         | [ٱ]         | [ٱ]         |
|             | {dir="rtl"} | {dir="rtl"} | {dir="rtl"} | {dir="rtl"} |
|             | Mexic       | Mexic       | Mexic       | Mexic       |
|             | an-American | an-American | an-American | an-American |
|             |             |             |             |             |
|             | [ٱ]         | [ٱ]         | [ٱ]         | [ٱ]         |
|             | {dir="rtl"} | {dir="rtl"} | {dir="rtl"} | {dir="rtl"} |
|             | Other       | Other       | Other       | Other       |
|             | Hispanic\   | Hispanic\   | Hispanic\   | Hispanic\   |
|             | _\_\_\_\_\_ | _\_\_\_\_\_ | _\_\_\_\_\_ | _\_\_\_\_\_ |
|             |             |             |             |             |
|             | [ٱ]         | [ٱ]         | [ٱ]         | [ٱ]         |
|             | {dir="rtl"} | {dir="rtl"} | {dir="rtl"} | {dir="rtl"} |
|             | Native      | Native      | Native      | Native      |
|             | American    | American    | American    | American    |
|             |             |             |             |             |
|             | [ٱ]         | [ٱ]         | [ٱ]         | [ٱ]         |
|             | {dir="rtl"} | {dir="rtl"} | {dir="rtl"} | {dir="rtl"} |
|             | Other       | Other       | Other       | Other       |
|             | \_\_        | \_\_        | \_\_        | \_\_        |
|             | \_\_\_\_\_\ | \_\_\_\_\_\ | \_\_\_\_\_\ | \_\_\_\_\_\ |
|             | _\_\_\_\_\_ | _\_\_\_\_\_ | _\_\_\_\_\_ | _\_\_\_\_\_ |
+-------------+-------------+-------------+-------------+-------------+

Table 2: Family Members Screening for the FIND Study

MALD Screening for Spouse and Child for the FIND Study

+-----------+----------+----------+----------+----------+----------+
|           | Proband  | Mother   | Father   | Sib/1    | Sib/2    |
|           |          | or       | or Child |          |          |
|           |          | Spouse   |          |          |          |
+-----------+----------+----------+----------+----------+----------+
| Ethnicity |          | [ٱ]{di   | [ٱ]{di   | [ٱ]{di   | [ٱ]{di   |
|           |          | r="rtl"} | r="rtl"} | r="rtl"} | r="rtl"} |
|           |          | African- | African- | African- | African- |
|           |          | American | American | American | American |
|           |          |          |          |          |          |
|           |          | [ٱ]{di   | [ٱ]{di   | [ٱ]{di   | [ٱ]{di   |
|           |          | r="rtl"} | r="rtl"} | r="rtl"} | r="rtl"} |
|           |          | E        | E        | E        | E        |
|           |          | uropean- | uropean- | uropean- | uropean- |
|           |          | American | American | American | American |
|           |          |          |          |          |          |
|           |          | [ٱ]{di   | [ٱ]{di   | [ٱ]{di   | [ٱ]{di   |
|           |          | r="rtl"} | r="rtl"} | r="rtl"} | r="rtl"} |
|           |          | Mexican- | Mexican- | Mexican- | Mexican- |
|           |          | American | American | American | American |
|           |          |          |          |          |          |
|           |          | [ٱ]{di   | [ٱ]{di   | [ٱ]{di   | [ٱ]{di   |
|           |          | r="rtl"} | r="rtl"} | r="rtl"} | r="rtl"} |
|           |          | Other    | Other    | Other    | Other    |
|           |          | Hisp     | Hisp     | Hisp     | Hisp     |
|           |          | anic\_\_ | anic\_\_ | anic\_\_ | anic\_\_ |
|           |          | \_\_\_\_ | \_\_\_\_ | \_\_\_\_ | \_\_\_\_ |
|           |          |          |          |          |          |
|           |          | [ٱ]{di   | [ٱ]{di   | [ٱ]{di   | [ٱ]{di   |
|           |          | r="rtl"} | r="rtl"} | r="rtl"} | r="rtl"} |
|           |          | Native   | Native   | Native   | Native   |
|           |          | American | American | American | American |
|           |          |          |          |          |          |
|           |          | [ٱ]{di   | [ٱ]{di   | [ٱ]{di   | [ٱ]{di   |
|           |          | r="rtl"} | r="rtl"} | r="rtl"} | r="rtl"} |
|           |          | Other    | Other    | Other    | Other    |
|           |          | \_       | \_       | \_       | \_       |
|           |          | \_\_\_\_ | \_\_\_\_ | \_\_\_\_ | \_\_\_\_ |
|           |          | \_\_\_\_ | \_\_\_\_ | \_\_\_\_ | \_\_\_\_ |
|           |          | \_\_\_\_ | \_\_\_\_ | \_\_\_\_ | \_\_\_\_ |
+-----------+----------+----------+----------+----------+----------+
| Barcode   |          |          |          |          |          |
| ID        |          |          |          |          |          |
+-----------+----------+----------+----------+----------+----------+
| Name/Addr |          | [ٱ]{di   | [ٱ]{di   | [ٱ]{di   | [ٱ]{di   |
| ess/Phone |          | r="rtl"} | r="rtl"} | r="rtl"} | r="rtl"} |
| \# or     |          | proband  | proband  | proband  | proband  |
| note that |          | will     | will     | will     | will     |
| proband   |          | contact  | contact  | contact  | contact  |
| intends   |          |          |          |          |          |
| to        |          |          |          |          |          |
| contact   |          |          |          |          |          |
| this      |          |          |          |          |          |
| person    |          |          |          |          |          |
+-----------+----------+----------+----------+----------+----------+
| Current   |          |          |          |          |          |
| Age       |          |          |          |          |          |
+-----------+----------+----------+----------+----------+----------+
| Gender    |          | FEMALE   | MALE     |          |          |
+-----------+----------+----------+----------+----------+----------+
| Diabetes  | Age      | Age      | Age      | Age      | Age      |
| (age at   | \_       | \_       | \_       | \_       | \_       |
| onset or  | \_\_\_\_ | \_\_\_\_ | \_\_\_\_ | \_\_\_\_ | \_\_\_\_ |
| yr of     |          | \_\_\_\_ | \_\_\_\_ | \_\_\_\_ | \_\_\_\_ |
| d         | or       |          |          |          |          |
| iagnosis) |          | or       | or       | or       | or       |
| **X** if  | Year\_   |          |          |          |          |
| not       | \_\_\_\_ | Year     | Year     | Year     | Year     |
| diabetic  |          | \_       | \_       | \_       | \_       |
| or **?**  |          | \_\_\_\_ | \_\_\_\_ | \_\_\_\_ | \_\_\_\_ |
| if        |          | \_\_\_\_ | \_\_\_\_ | \_\_\_\_ | \_\_\_\_ |
| unknown   |          |          |          |          |          |
+-----------+----------+----------+----------+----------+----------+
| Kidney    | Age      | Age      | Age      | Age      | Age      |
| disease   | \_       | \_       | \_       | \_       | \_       |
| (age at   | \_\_\_\_ | \_\_\_\_ | \_\_\_\_ | \_\_\_\_ | \_\_\_\_ |
| onset or  |          | \_\_\_\_ | \_\_\_\_ | \_\_\_\_ | \_\_\_\_ |
| yr of     | or       |          |          |          |          |
| d         |          | or       | or       | or       | or       |
| iagnosis) | Year\_   |          |          |          |          |
| **X** if  | \_\_\_\_ | Year     | Year     | Year     | Year     |
| no KD or  |          | \_       | \_       | \_       | \_       |
| **?** if  |          | \_\_\_\_ | \_\_\_\_ | \_\_\_\_ | \_\_\_\_ |
| unknown   |          | \_\_\_\_ | \_\_\_\_ | \_\_\_\_ | \_\_\_\_ |
+-----------+----------+----------+----------+----------+----------+
| Hyp       | Age      | Age      | Age      | Age      | Age      |
| ertension | \_       | \_       | \_       | \_       | \_       |
| (age at   | \_\_\_\_ | \_\_\_\_ | \_\_\_\_ | \_\_\_\_ | \_\_\_\_ |
| onset or  |          | \_\_\_\_ | \_\_\_\_ | \_\_\_\_ | \_\_\_\_ |
| yr of     | or       |          |          |          |          |
| d         |          | or       | or       | or       | or       |
| iagnosis) | Year\_   |          |          |          |          |
| **X** if  | \_\_\_\_ | Year     | Year     | Year     | Year     |
| no HTN    |          | \_       | \_       | \_       | \_       |
| or**?**   |          | \_\_\_\_ | \_\_\_\_ | \_\_\_\_ | \_\_\_\_ |
| if        |          | \_\_\_\_ | \_\_\_\_ | \_\_\_\_ | \_\_\_\_ |
| unknown   |          |          |          |          |          |
+-----------+----------+----------+----------+----------+----------+
| Eye       | Age      | Age      | Age      | Age      | Age      |
| disease   | \_       | \_       | \_       | \_       | \_       |
| (age at   | \_\_\_\_ | \_\_\_\_ | \_\_\_\_ | \_\_\_\_ | \_\_\_\_ |
| onset or  |          | \_\_\_\_ | \_\_\_\_ | \_\_\_\_ | \_\_\_\_ |
| yr of     | or       |          |          |          |          |
| d         |          | or       | or       | or       | or       |
| iagnosis) | Year\_   |          |          |          |          |
|           | \_\_\_\_ | Year     | Year     | Year     | Year     |
| **X** if  |          | \_       | \_       | \_       | \_       |
| no ED or  |          | \_\_\_\_ | \_\_\_\_ | \_\_\_\_ | \_\_\_\_ |
| **?** if  |          | \_\_\_\_ | \_\_\_\_ | \_\_\_\_ | \_\_\_\_ |
| unknown)  |          |          |          |          |          |
+-----------+----------+----------+----------+----------+----------+
| Does      |          |          |          |          |          |
| proband   |          |          |          |          |          |
| think     |          |          |          |          |          |
| this      |          |          |          |          |          |
| person    |          |          |          |          |          |
| will      |          |          |          |          |          |
| pa        |          |          |          |          |          |
| rticipate |          |          |          |          |          |
| ?         |          |          |          |          |          |
+-----------+----------+----------+----------+----------+----------+
| Eligible  |          |          |          |          |          |
| for FIND  |          |          |          |          |          |
| (**Y** or |          |          |          |          |          |
| **N)** if |          |          |          |          |          |
| Y give    |          |          |          |          |          |
| study ID  |          |          |          |          |          |
+-----------+----------+----------+----------+----------+----------+

Table #2: Extension Page Family Members Screening for the FIND Study

+------------+------------+------------+--------------+--------------+
|            | **Sib/3**  | **Sib/4**  | **Sib/5**    | **Sib/6**    |
+------------+------------+------------+--------------+--------------+
| Ethnicity  | [ٱ]{       | [ٱ]{       | [ٱ           | [ٱ           |
|            | dir="rtl"} | dir="rtl"} | ]{dir="rtl"} | ]{dir="rtl"} |
|            | Africa     | Africa     | Afri         | Afri         |
|            | n-American | n-American | can-American | can-American |
|            |            |            |              |              |
|            | [ٱ]{       | [ٱ]{       | [ٱ           | [ٱ           |
|            | dir="rtl"} | dir="rtl"} | ]{dir="rtl"} | ]{dir="rtl"} |
|            | Europea    | Europea    | Europ        | Europ        |
|            | n-American | n-American | ean-American | ean-American |
|            |            |            |              |              |
|            | [ٱ]{       | [ٱ]{       | [ٱ           | [ٱ           |
|            | dir="rtl"} | dir="rtl"} | ]{dir="rtl"} | ]{dir="rtl"} |
|            | Mexica     | Mexica     | Mexi         | Mexi         |
|            | n-American | n-American | can-American | can-American |
|            |            |            |              |              |
|            | [ٱ]{       | [ٱ]{       | [ٱ           | [ٱ           |
|            | dir="rtl"} | dir="rtl"} | ]{dir="rtl"} | ]{dir="rtl"} |
|            | Other      | Other      | Other        | Other        |
|            | Hispanic\_ | Hispanic\_ | Hispanic     | Hispanic     |
|            | \_\_\_\_\_ | \_\_\_\_\_ | \_\_\_\_\_\_ | \_\_\_\_\_\_ |
|            |            |            |              |              |
|            | [ٱ]{       | [ٱ]{       | [ٱ           | [ٱ           |
|            | dir="rtl"} | dir="rtl"} | ]{dir="rtl"} | ]{dir="rtl"} |
|            | Native     | Native     | Native       | Native       |
|            | American   | American   | American     | American     |
|            |            |            |              |              |
|            | [ٱ]{       | [ٱ]{       | [ٱ           | [ٱ           |
|            | dir="rtl"} | dir="rtl"} | ]{dir="rtl"} | ]{dir="rtl"} |
|            | Other      | Other      | Other        | Other        |
|            | \_\_\_     | \_\_\_     | \_           | \_           |
|            | \_\_\_\_\_ | \_\_\_\_\_ | \_\_\_\_\_\_ | \_\_\_\_\_\_ |
|            | \_\_\_\_\_ | \_\_\_\_\_ | \_\_\_\_\_\_ | \_\_\_\_\_\_ |
+------------+------------+------------+--------------+--------------+
| Barcode ID |            |            |              |              |
+------------+------------+------------+--------------+--------------+
| Name/Add   |  proband  |  proband  |  proband    |  proband    |
| ress/Phone | will       | will       | will contact | will contact |
| \# or note | contact    | contact    |              |              |
| that       |            |            |              |              |
| proband    |            |            |              |              |
| intends to |            |            |              |              |
| contact    |            |            |              |              |
| this       |            |            |              |              |
| person     |            |            |              |              |
+------------+------------+------------+--------------+--------------+
| Current    |            |            |              |              |
| Age        |            |            |              |              |
+------------+------------+------------+--------------+--------------+
| Gender     |            |            |              |              |
+------------+------------+------------+--------------+--------------+
| Diabetes   | Age        | Age        | Age          | Age          |
| (age at    | \_\_\_\_   | \_\_\_\_   | \_\_\_       | \_\_\_       |
| onset or   | \_\_\_\_\_ | \_\_\_\_\_ | \_\_\_\_\_\_ | \_\_\_\_\_\_ |
| yr of      |            |            |              |              |
| diagnosis) | or         | or         | or           | or           |
| **X** if   |            |            |              |              |
| not        | Year       | Year       | Year         | Year         |
| diabetic   | \_\_\_\_   | \_\_\_\_   | \_\_\_       | \_\_\_       |
| or **?**   | \_\_\_\_\_ | \_\_\_\_\_ | \_\_\_\_\_\_ | \_\_\_\_\_\_ |
| if unknown |            |            |              |              |
+------------+------------+------------+--------------+--------------+
| Kidney     | Age        | Age        | Age          | Age          |
| disease    | \_\_\_\_   | \_\_\_\_   | \_\_\_       | \_\_\_       |
| (age at    | \_\_\_\_\_ | \_\_\_\_\_ | \_\_\_\_\_\_ | \_\_\_\_\_\_ |
| onset or   |            |            |              |              |
| yr of      | or         | or         | or           | or           |
| diagnosis) |            |            |              |              |
| **X** if   | Year       | Year       | Year         | Year         |
| no KD or   | \_\_\_\_   | \_\_\_\_   | \_\_\_       | \_\_\_       |
| **?** if   | \_\_\_\_\_ | \_\_\_\_\_ | \_\_\_\_\_\_ | \_\_\_\_\_\_ |
| unknown    |            |            |              |              |
+------------+------------+------------+--------------+--------------+
| Hy         | Age        | Age        | Age          | Age          |
| pertension | \_\_\_\_   | \_\_\_\_   | \_\_\_       | \_\_\_       |
| (age at    | \_\_\_\_\_ | \_\_\_\_\_ | \_\_\_\_\_\_ | \_\_\_\_\_\_ |
| onset or   |            |            |              |              |
| yr of      | or         | or         | or           | or           |
| diagnosis) |            |            |              |              |
| **X** if   | Year       | Year       | Year         | Year         |
| no HTN     | \_\_\_\_   | \_\_\_\_   | \_\_\_       | \_\_\_       |
| or**?** if | \_\_\_\_\_ | \_\_\_\_\_ | \_\_\_\_\_\_ | \_\_\_\_\_\_ |
| unknown    |            |            |              |              |
+------------+------------+------------+--------------+--------------+
| Eye        | Age        | Age        | Age          | Age          |
| disease    | \_\_\_\_   | \_\_\_\_   | \_\_\_       | \_\_\_       |
| (age at    | \_\_\_\_\_ | \_\_\_\_\_ | \_\_\_\_\_\_ | \_\_\_\_\_\_ |
| onset or   |            |            |              |              |
| yr of      | or         | or         | or           | or           |
| diagnosis) |            |            |              |              |
|            | Year       | Year       | Year         | Year         |
| **X** if   | \_\_\_\_   | \_\_\_\_   | \_\_\_       | \_\_\_       |
| no ED or   | \_\_\_\_\_ | \_\_\_\_\_ | \_\_\_\_\_\_ | \_\_\_\_\_\_ |
| **?** if   |            |            |              |              |
| unknown)   |            |            |              |              |
+------------+------------+------------+--------------+--------------+
| Does       |            |            |              |              |
| proband    |            |            |              |              |
| think this |            |            |              |              |
| person     |            |            |              |              |
| will       |            |            |              |              |
| pa         |            |            |              |              |
| rticipate? |            |            |              |              |
+------------+------------+------------+--------------+--------------+
| Eligible   |            |            |              |              |
| for FIND   |            |            |              |              |
| (**Y** or  |            |            |              |              |
| **N)** if  |            |            |              |              |
| Y give     |            |            |              |              |
| study ID   |            |            |              |              |
+------------+------------+------------+--------------+--------------+

+-------------------------------+--------------------------------------+
| **FIND Medical Record         |                                      |
| Review**                      |                                      |
+-------------------------------+--------------------------------------+
| **Barcode and**               | Study Coordinator ID                 |
|                               | \_\_\_\_\_\_\_\_\_\_\_\_\_           |
| **Participant ID**            |                                      |
|                               | Date of review (*MM/DD/YYYY*) \_\_   |
|                               | \_\_ \| \_\_ \_\_ \| \_\_ \_\_ \_\_  |
|                               | \_\_                                 |
+-------------------------------+--------------------------------------+

***Instruction to record abstractor***: During review of the medical
record(s), please review the Medical Questionnaire (Form 01), since it
may be necessary to add or correct some data on the questionnaire (e.g.,
medicines or date of onset of diabetes or dialysis).

RECORD TYPE

1\. Indicate type of record(s) reviewed (*Mark all that apply*).

> Dialysis unit
>
> Primary care (*Including records from the endocrinologist and/or
> nephrologist*)
>
> Hospital
>
> Other

# PARTICIPANT INFORMATION

2.  **Name**:

> *Last First Middle Maiden*

3.  **Number range level0Number range level1Number range level2Number
    range level3Number range level4Number range level5Number range
    level6Number range level7Birth date** (*MM/DD/YYYY*): \_\_ \_\_ \|
    \_\_ \_\_ \| \_\_ \_\_ \_\_ \_\_

4.  **Sex:**  FEMALE  MALE

KIDNEY DISEASE

**Kidney Disease**

5.  **Is the level of urinary protein/albumin recorded in the record**?

No Yes

If **Yes**, then specify the following (*Mark the maximum value only*):

[Protein excretion rate]{.underline} [P/C ratio]{.underline} [Albumin
excretion rate]{.underline} [A/C ratio]{.underline}

a.   \<50 mg/24h **or** \<0.15 mg/mg **or** \<30 mg/24h **or** \<0.03
    mg/mg

b.   ≥50 mg/24h **or** ≥0.15 mg/mg **or** ≥30 mg/24h **or** ≥0.03 mg/mg

c.   ≥500 mg/24h **or** ≥0.5 mg/mg **or** ≥300 mg/24h **or** ≥0.3 mg/mg

d.   ≥1.0 g/24h **or** ≥1.0 mg/mg **or** ≥1.0 g/24h **or** ≥1.0 mg/mg

e.   ≥3.0 g/24h **or** ≥3.0 mg/mg **or** ≥3.0 g/24h **or** ≥3.0 mg/mg

f.   Nephrotic ( 3.0g -- 3.5g)

g.   None

If **a**, record date of **LAST** value (*MM/DD/YYYY*): \_\_ \_\_ \|
\_\_ \_\_ \| \_\_ \_\_ \_\_ \_\_

Also record whether subject is receiving antihypertensive therapy at
**LAST** value: No Yes

**HIGHEST** value: No Yes

If **e**, record date of **FIRST** value at this level (*MM/DD/YYYY*):
\_\_ \_\_ \| \_\_ \_\_ \| \_\_ \_\_ \_\_ \_\_

  -------------------------------- ---- ----------------------------------
  ***Equivalent Measures of             
  Urinary Albumin Excretion***          

  30 mg/24h                        =    20 μg/min

  300 mg/24h                       =    200 μg/min
  -------------------------------- ---- ----------------------------------

If the excretion reported above is a ratio, record the urine protein
(albumin) and creatinine concentrations:

Urine protein (*mg/l*) \_\_ \_\_ \_\_ \_\_ \_\_ . \_\_ **or** Urine
albumin (*mg/l*) \_\_ \_\_ \_\_ \_\_ \_\_ . \_\_

Urine creatinine (*g/l*) \_\_ . \_\_ \_\_

6.  **Is the participant receiving chronic renal replacement therapy**?

 No Yes If **Yes**, record the date of onset (*MM/DD/YYYY*): \_\_ \_\_
\| \_\_ \_\_ \| \_\_ \_\_ \_\_ \_\_

Yes AA MALD with Nephropathy but no DM

If **No**, record the **HIGHEST** serum creatinine concentration
(*mg/dl*): \_\_ \_\_ . \_\_

Date of **HIGHEST** serum creatinine concentration (*MM/DD/YYYY*): \_\_
\_\_ \| \_\_ \_\_ \| \_\_ \_\_ \_\_ \_\_

7.  **Primary cause of kidney failure / renal insufficiency (*Mark all
    that apply*)**?

Diabetes Polycystic kidney disease

Hypertension Lupus nephritis

 IgA nephropathy Kidney cancer

 Membranous glomerulonephritis Obstruction

Focal glomerulosclerosis Don't know

Other None

8.  **Is a kidney biopsy recorded in the record**?

No Yes If **Yes**, record the biopsy date (*MM/DD/*YYYY): \_\_ \_\_ \|
\_\_ \_\_ \| \_\_ \_\_ \_\_ \_\_

If **Yes**, specify methods of evaluation (*Mark all that apply*).

Light microscopy Electron microscopy Immunofluorescence

Also specify the histologic findings (*Mark all that apply*).

Increased nodular mesangial matrix.

Increased diffuse mesangial matrix.

Thickened glomerular basement membrane.

Arterial hyalinization.

Arteriolar hyalinization.

Mesangial immunoglobulin or paraprotein deposits by immunofluorescence.

Amyloid deposits by Congo red staining or electron microscopy.

Electron dense deposits within the glomerular basement membrane or
glomerular capillary subendothelial space.

 Non-Diabetic Pahtological Diagnosis

HISTORY OF DIABETES

9.  **Has a diagnosis of diabetes been made**?

 No  Yes

If Yes, record the source of the diagnosis (*Mark all that apply*):

Fasting plasma glucose ≥ 126 mg/dl (or venous whole blood glucose ≥ 110
mg/dl or capillary whole blood glucose ≥ 110 mg/dl) \*

 Random plasma glucose ≥ 200 mg/dl (or venous whole blood glucose ≥ 180
mg/dl or capillary whole blood glucose ≥ 200 mg/dl) \* and symptoms
(*polyuria, polydipsia, polyphagia*).

 Two-hour post-load plasma glucose ≥ 200 mg/dl (or venous whole blood
glucose ≥ 180 mg/dl or capillary whole blood glucose ≥ 200 mg/dl) \*
(*OGTT*).

 Clinical diagnosis without documented plasma glucose concentration.

Record the earliest date of diagnosis (*MM/DD/YYYY*): \_\_ \_\_ \| \_\_
\_\_ \| \_\_ \_\_ \_\_ \_\_

\*The measurement of glucose in serum is discouraged by the WHO (World
Health Organization). Unless the red cells are immediately removed to
prevent glycolysis, serum samples should not be used for diagnosing
diabetes. If only serum glucose values are found in the record, however,
they should be interpreted as if they were plasma values.

10. **Is a diagnosis of diabetic ketoacidosis or diabetic coma recorded
    in the record**?

No Yes

DIABETIC EYE DISEASE

11. **Is a diagnosis of diabetic retinopathy recorded in the record**?

No Yes

If **Yes**, specify the severity of the retinopathy (*Mark all that
apply*).

Background retinopathy Vitreous hemorrhage

Pre-proliferative retinopathy Macular edema

Proliferative retinopathy Photocoagulation therapy