Patient History form for : Yakrut Arbud (Hepatocellular Carcinoma)

Name : *

Age : *

Gender *
 Male Female

Address :


City : *

Zip Code : *

Country : *

Phone Number : *

E-mail : *

Do you have any pain in abdomen ?
 Yes No

Is there any fullness of stomach ?
 Yes No

Are you suffering from Nausea or vomiting ?
 Yes No

Are you suffering from free fluid in abdomen (ascites) ?
 Yes No Don’t Know

Is there any deep yellow discoloration of eyes, skin, urine ?
 Yes No

Do you feel loss of energy?
 Yes No

What type of food do you use in food ?
 Vegetarian Non Vegetarian

Do you use alcohol ?
 Yes No

Do you smoke ?
 Yes No

Do you exercise regularly ?
 Yes No

Do you use any pain killer medicines ?
 Yes No

Do you have any tests reports done ? If yes then kindly upload reports (10 MB Maximum File Size.... Preferably send zip files. If you have more files then email separately to drharishverma@gmail.com)

Do you have any current medication going on ? If yes then describe below

If you have any other information to share then please describe below :


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