Patient Registration
Dr Santhosh Kumar , Gastroenterologist
Full Name
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First Name
Last Name
What is your age?
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What is your gender?
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Male
Female
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Contact Number
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Email Address
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Appointment
Check the conditions that apply to you or any member of your immediate relatives:
Asthma
Cancer
Cardiac disease
Diabetes
Hypertension
Psychiatric disorder
Epilepsy
Other
Check the symptoms that you' re currently experiencing:
Chest pain/ discomfort/ heartburn /excessive burping/repeated throat infection/ sore throat
Cough
Swallowing difficulty
Upper abdomen pain/discomfort
Central abdomen pain/ discomfort
Lower abdomen pain/ discomfort
Significant weight loss / significant weight gain over last few months
Excessive farting/ Gassy feeling/ bloated sensation
Stools/motions - loose / hard / mixed with blood / mixed with mucus / frequent stools
Vomiting
Fever
Jaundice / dark coloured urine / itching
Reduced appetite
Other
Are you currently taking any medication?
Yes
No
Please list them.
Do you have any medication allergies?
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No
Not Sure
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Do you use any kind of tobacco or have you ever used them?
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Yes
No
What kind of tobacco products? How long have you used/been using them?
What kind of drugs? How long have you used/been using them?
How often do you consume alcohol?
Daily
Weekly
Monthly
Occasionally
Never
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Dr Santhosh Kumar , Gastroenterologist
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