Patient History Form – Rakatatisaar ( Ulcerative Colitis )

Name : *

Age : *

Gender *
 Male Female

Address :

City : *

Zip Code : *

Country : *

Phone Number : *

E-mail : *

When was your diagnosis of Ulcerative Colitis or Crohn’s disease made?

How many times you have visit toilet to pass stools?

What is the consistency of stool?
 Loose Semi Solid Formed

Are you passing BLOOD in stool?
 Yes No

How many times you have visit toilet to pass stools?

Is there an urgency to go to toilet?
 Yes No

Do you have a pain in abdomen ?
 Yes No

Do you feel loss of energy?
 Yes No

Have you lost weight in recent past?
 Yes No

What is your Haemoglobin level?

Do you have any blood test report? If Yes, then please attach the scan copies of blood report. (10 MB Maximum File Size.... Preferably send zip files. If you have more files then email separately to

What Medicines are you taking presently?

Do you have any other disease (like Diabetes, Hypertension, Arthritis etc.)

Mention the details of details previous illnesses you have suffered in the past:

Do you have any other information to share?

Any other questions and queries?

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