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

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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