Prune Belly Syndrome Network Registry

Prune Belly Syndrome Network, Inc.
"You are NOT the only one!"

Patient Registry

Please take a minute to fill out the form below. To better meet the needs of the Network it is important that as much information about Prune Belly is obtained from as many people as possible. If you found the website to be helpful please consider sponsoring the Network by donating whatever you can. Please go to the Contributions page for further details.

Any information you provide will remain strictly confidential. With your co-operation there will be no limit to the services that the PBSN can one day provide. Please write to jking@prunebelly.org if you have any questions or comments.

Please note: Although it is most unlikely that you will experience any problems responding to this form, certain non-standard browsers will not respond properly. If you experience any difficulties, (or if you are not using a forms-capable browser) you may email your response to this form to: jking@prunebelly.org.

This form does not register you for the Support Forum. Support forum registration is done on the Support Forum.

*First Name:

Last Name:

*Email:

Web Page:

Address:

City:

State/Prov.:

Zip Code:

Country:

How did you find the PBSN?

Who has Prune Belly:

Level of Education:

Gender:

Age:

Does the person with Prune Belly:
Self Catheterize?	Take antibiotics routinely?
Have UTIs?

What other areas are involved? Please check any that apply.

None?	Respiratory:
Gastrointestinal: Skeletal: Endocrine:	Hematology: Vision: Hearing:
Learning Disability:
What types of health care do you access? Please check all that apply.
None: Urologist: Nephrologist:	Pulmonologist: Endocrinologist: Orthopedist:
Podiatrist: Physical Therapist: Speech Therapist: Occupational Therapist:	Social Worker: Home Care: Early Intervention: Special Education:
Please comment on the medical status of the person with Prune Belly. Include surgeries if any, current renal function, method of voiding urine, any other problems or concerns. How well are things overall. Include any additional information you would like to see on the website.
Permission to share this information with medical doctors and researchers.

Thank you for your input.

Patient Registry

Thank you for your input.