Question number | Question | Response |
1 | Name |
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2 | File number |
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3 | Dated |
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4 | Age |
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5 | Gender | 1. Male 2. Female |
6 | Occupation |
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7 | Address |
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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 |
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13B | State previous endoscopic findings |
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13C | State previous biopsy report |
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