Demographic information

Todays date
-------------------------
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

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 --------

Medical information
Current health
a. Good b. fair c. better
Name of physician

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 -----------
Do you have any allergies?
a. Yes b. no c. other
Do you have any sensitivity to pharmaceuticals or other substances?
a. Yes b. no
Blood glucose level
a. Normal b. hypoglycemia c. hyperglycemia
Blood pressure and pulse rate?
a. Hypotensive b. normal c. hypertensive
Date of admission?

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

Current 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
Do you have depression?
a. Yes b. no
Do you feel nausea /vomiting?
a. Yes b. no
What is the color of the urine?
a. Transparent b. dark c. yellow
From how much time you are taking therapy?
a. 1 month b. 1 year c. > 1 year

Treatment
What is the treatment prescribed by the doctor?
a. Interferons b. antivirals c. both
What is the dose of medication?

Are you having any other supportive therapy?

a. Antibiotics b. liver tonic c. NSAID d. other ---------------

Side effects /ADRs

Do you ever diagnose by hemolytic anemia during treatment?
a. Yes b. no
Do you ever diagnose by depression during treatment?
a. Yes b. no
Do you ever feel fatigue during treatment?
a. Yes b. no
Hows your sleep?
a. Insomnia b. normal c. over sleep
 Interactions
Any drug - drug interactions?

Any drug food interactions?

Any drug disease interactions?