Patient questionnaire to determine the composition of urinary stones
Please fill out the form with as much detail as possible
Your Last Name, First Name, Middle Name
Your e-mail
Your phone number for contact
Please select your gender:
male
female
Please enter your date of birth and/or your age
Enter the name of your treating doctor
How was the stone removed?
Surgically (operation)
on ones own
Permanent address:
Place of Birth:
Occupation
Have you ever been treated with urolithiasis before?
No
Yes
Please select the diseases you have:
Diabetes mellitus
Gout
Hypertension
Overweight
Infectious diseases of the genitourinary system
Congenital renal disease
Urinary disorders
Rheumatoid arthritis
Crohns disease
Ulcerous colitis
Chronic pancreatitis
Chronic pyelonephritis
Kidney failure
Salt abuse
Abuse of animal protein (including eggs, meat)
Diseases of the thyroid and / or parathyroid glands
Abuse of chocolate, coffee and cola
Nothing
How do you want to receive a conclusion?
Electronically by E-mail
Electronically to your phone (WhatsApp, Telegram)
Paper version
Submit
Additional Information
The analysis time is 2-5 working days, on average 3 days. The results will be sent to you using the specified method.