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Questionnaire

Patient Bio Data:


Name

Age
a. 1-6 months b. 1-12years c. 15 -25 years d. >25
Gender
a. Male b. female
Marial status
a. Married b. unmarried
Address

Occupation
a. employed b. unemployed c. businessmen d. other
Monthly Income

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:

Do you receive vaccine if Hepatitis?


a. Yes b. no
From how much time you are suffering from hepatitis?
a. 1week b. 1 month c. 1year d. >1 year
What was the symptom that appears initially?
a. Fever b. Pale eyes/skin c. Abdominal Pain d. Other----------
When did you consult the physician?
a. Immediately b. after some days c. after few weeks d. over a month
What was the treatment given by doctor?
a. Antibiotics b. Antipyretic c. Multivitamins d. Other---------
How did you come to know that youre suffering from Hepatitis?
a. Personal Interpretation b. any friends suggestion c. Doctor suggest clinical lab test
In the past did you use any injections?
a. Yes b. No c. If yes, then What, Why and for how much time--------
Did you transfuse blood and any blood product in the past ?
a. Yes b. never c. if yes ,specify---------
Did the patient receive any organ transplant ?
a. Yes b. no c. if yes, specify ---------
Are you suffering with any other disease?
a. Yes b. no c. if yes , specify --------
Diagnosis
What were the general test specified by the doctor ?
a. CBC b. serum albumin c. LFT d. other, specify---------
What was the inference ?
a. Increase SGPT/SGOT b. increase albumin c. other -----------
Blood glucose level
a. Normal b. hypoglycemia c. hyperglycemia
Blood pressure and pulse rate ?
a. Hypotensive b. normal c. hypertensive
Specific tests
Anti HCV screening result ?
a. Reactive b. non reactive
HCV RNA test (PCR)?
a. Posivtive b. negative c. unknown
Supplemental anti HCV?
a. Positive b. negative c. unknown
Cureent disease bio data
For how long has you know that you have hepatitis ?
a. 1 year b. 2-5 year c. more than 5 years
When did you visit your doctor last time?
a. Last week b. last month c. over a month
What is the condition of current disease ?
a. Better b. worsen c. same
Do you have fever with this disease ?
a. Yes b. no
Is the color of skin pale ?
a. Yes b. no
Is the color of eye pale?
a. Yes b. no
Do you feel abdominal pain ?
a. Yes b. no