The Information shubmitted by shall not be disclosed to any third party and shall be used for the purpose of reviewing the status of your disease condition and stage. Submit the details asked in this form and we will get back to you in a day. Name Phone Number Email Address Age Gender MaleFemaleOther Street Address Address Line 2 City State Postal Zip Code Country AfghanistanAlbaniaAlgeriaAndorraAngolaAntigua & BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia & HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiaComorosCongoCongo Democratic RepublicCosta RicaCote d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEast TimorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambiaGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea NorthKorea SouthKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmar (Burma)NamibiaNauruNepalThe NetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalauPalestinian State*PanamaPapua New GuineaParaguayPeruThe PhilippinesPolandPortugalQatarRomaniaRussiaRwandaSt. Kitts & NevisSt. LuciaSt. Vincent & The GrenadinesSamoaSan MarinoSao Tome & PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth SudanSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad & TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited States of AmericaUruguayUzbekistanVanuatuVatican City (Holy See)VenezuelaVietnamYemenZambiaZimbabwe When your diagnosis of Hepatitis was made ? Is HCV RNA Test Positive in your blood? YesNo Are you suffering from Jaundice (Yellow discoloration of eyes, urine or skin) YesNo Are you suffering from Ascites (Free fluid in abdomen) YesNoDon't Know Are you suffering from Low-grade fever ? YesNo Are you suffering from Nausea or vomiting ? YesNo Do you feel loss of energy ? YesNo Are you suffering from Blood in vomiting (Hematemesis)? YesNo Are you suffering from Headaches/ Body aches? YesNo Is HbsAg Test Positive in your blood ? YesNo Have you lost weight in recent past ? YesNo What is your Viral Load Count/ Hemoglobin Level / Platlet Count / SGPT-SGOT Levels / Total Bilirubin Levels ? (if you dont know, please write "Dont Know") Please mention all the main complaints with their duration. In case certain complaints, which are not permanent but occur occasionally, you should also mention details of those complaints. Also specify if there is any relation of your complaint with food, life style, rest, exercise, season, medication, work place, occupation etc. What medicines are you taking currently ? Mention the details of details previous illnesses you have suffered in the past (e.g. viral infections, injuries, systemic diseases etc.) along with the age of onset, duration and outcome? Do you have any other information to share ? What is 4 + 1 ?
