Академический Документы
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Todays date
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Name
Age
a. 1-6 months b. 1-12years c. 15 -25 years d. >25
Gender
a. Male b. female
Marital status
a. Married b. unmarried
Date of Birth
Address
Contact number
Occupation
a. employed b. unemployed c. businessmen d. other
Monthly Income
Person completing this form?
a. self b. other
Physical appearance
a. underweight b. average c. overweight
Do you smoke?
a. Yes b. no
Are you alcoholic?
a. Yes b. no
Hows your working and living environment?
a. Hygienic b. non hygienic
Mental status
a. Mentally retarted b. normal
Suffers from any genetic disorder?
a. Yes b. no c. if yes, specify --------------
Attitude
a. Friendly b. normal c. rude
Any of the family member diagnosed hepatitis earlier?
a. Yes b. no c. if yes, specify -----------
Previous History
Medical information
Current health
a. Good b. fair c. better
Name of physician
Specific tests
Anti HCV screening result?
a. Reactive b. nonreactive
HCV RNA test (PCR)?
a. Positive b. negative c. unknown
Supplemental anti HCV?
a. Positive b. negative c. unknown
Treatment
What is the treatment prescribed by the doctor?
a. Interferons b. antivirals c. both
What is the dose of medication?