55

Dated

56

State the region(s) where endoscopy was performed

1. Esophagus 2. Stomach 2i. Fundus 2ii. Body 2iii. Antrum 2iv. Pylorus 3. Duodenum

57

Normal upper G. I. mucosa

1. Yes 2. No

58

Reflux esophagitis grade

____

59

Gastroesophageal reflux disease

1. Yes 2. No

60

Lax esophageal sphincter

1. Yes 2. No

61

Esophageal varices

1. Yes 2. No

62

Esophageal stricture

1. Yes 2. No

63

Carcinoma

1. Yes 2. No

64

Gastric varices

1. Yes 2. No

65

Gastritis

1. Yes 2. No

66

Gastric erosions

1. Yes 2. No

67

Gastric ulcer

1. Yes 2. No

68

Duodenitis

1. Yes 2. No

69

Duodenal ulcer

1. Yes 2. No

70

Portal gastropathy

1. Yes 2. No

71

Banding zone/dilatation zone

1. Yes 2. No

72

Other findings