Patient History Form - Hepatitis C Treatment

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For alternative treatment of Hepatitis C

Patient History Form

Submit your Hepatitis-C History

Submit your illness history for Hepatitis C to get medical consultation directly from Dr. Karun Verma

Name *

Age *

Gender *
MaleFemale

Address : *

Email *

Your Contact Phone No. *

When your diagnosis of Hepatitis was made? *

Are you suffering from Jaundice (Yellow discoloration of eyes, urine or skin) *
YesNo

Are you suffering from Ascites (Free fluid in abdomen) *
YesNo

Are you suffering from Low-grade fever ? *
YesNo

Are you suffering from Nausea or vomiting ? *
YesNo

Do you feel loss of energy ? *
YesNo

Are you suffering from Blood in vomiting (Hematemesis)? *
YesNo

Are you suffering from Headaches/ Body aches? *
YesNo

Is HbsAg Test Positive in your blood ? *
YesNoDon't know

Is HCV RNA Test Positive in your blood? *
YesNoDon't know

Have you lost weight in recent past ? *
YesNo

Do you have any blood test report ? *
YesNo

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

What is your Hemoglobin level? (ENTER NUMBER)

What is your viral Load ?

What is your Platelet count ?

What is your ALT (SGPT) level ?

What is your Total Billirubin level ?

Please mention all the main complaints with their duration. In case certain complaints, which are not permanent but occur occasionally, you should also mention details of those complaints. Also specify if there is any relation of your complaint with food, life style, rest, exercise, season, medication, work place, occupation etc. :

What is your Ultrasound/MRI/CT Scan Report ? (Send SCANNED report through separate email to drkarunverma@gmail.com)

What is the report of your Liver BIOPSY? (Send SCANNED report through separate email to drkarunverma@gmail.com)

What medicines are you taking currently ?

Mention the details of details previous illnesses you have suffered in the past (e.g. viral infections, injuries, systemic diseases etc.) along with the age of onset, duration and outcome. :

Do you have any other information to share ?