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Patient History Form Name : * Age : * Gender * MaleFemale Address : City : * Zip Code : * Country : * United States of AmericaCanadaIndiaAfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijan.Bahamas, TheBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurmaBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCote d'IvoireCroatiaCubaCuracaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (see Timor-Leste)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueNamibiaNauruNepalNetherlandsNetherlands AntillesNew ZealandNicaraguaNigerNigeriaNorth KoreaNorwayOmanPakistanPalauPalestinian TerritoriesPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited States of AmericaUruguayUzbekistanVanuatuVenezuelaVietnamYemenZambiaZimbabwe Phone Number : * E-mail : * When was your diagnosis of Ulcerative Colitis or Crohn’s disease made? What is the consistency of stool? LooseSemi SolidFormed Are you passing BLOOD in stool? YesNo How many times you have visit toilet to pass stools? Is there an urgency to go to toilet? YesNo Do you have a pain in abdomen ? YesNo Do you feel loss of energy? YesNo Have you lost weight in recent past? YesNo 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 drharishverma@gmail.com) 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? What Medicine you're taking ?
Name : * Age : * Gender * MaleFemale Address : City : * Zip Code : * Country : * United States of AmericaCanadaIndiaAfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijan.Bahamas, TheBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurmaBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCote d'IvoireCroatiaCubaCuracaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (see Timor-Leste)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueNamibiaNauruNepalNetherlandsNetherlands AntillesNew ZealandNicaraguaNigerNigeriaNorth KoreaNorwayOmanPakistanPalauPalestinian TerritoriesPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited States of AmericaUruguayUzbekistanVanuatuVenezuelaVietnamYemenZambiaZimbabwe Phone Number : * E-mail : * When was your diagnosis of Ulcerative Colitis or Crohn’s disease made? What is the consistency of stool? LooseSemi SolidFormed Are you passing BLOOD in stool? YesNo How many times you have visit toilet to pass stools? Is there an urgency to go to toilet? YesNo Do you have a pain in abdomen ? YesNo Do you feel loss of energy? YesNo Have you lost weight in recent past? YesNo 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 drharishverma@gmail.com) 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? What Medicine you're taking ?
