Question number

Question

Response

1

Name

2

File number

3

Dated

4

Age

5

Gender

1. Male 2. Female

6

Occupation

7

Address

8

Cigarette addiction

1. Yes 2. No

8A

If yes, state the duration

____/day for ____years

9

Addiction to betel leaf (Paan) with tobacco

1. Yes 2. No

9A

If yes, state the duration

____/day for ____years

10

Alcohol addiction

1. Yes 2. No

10A

If yes, state the duration

____/drinks per week for ____years

11

Niswaar addiction

1. Yes 2. No

11A

If yes, state the duration

____/day for ____years

12

Other addictions

For___ years

13

Previous endoscopy

1. Yes 2. No

13A

If yes, state the date at which the previous endoscopy was performed

13B

State previous endoscopic findings

13C

State previous biopsy report