welcome to hernia clinic!
IN THIS PART DR SACHIN KUBER WHO IS EXPERT IN HERNIA AND OTHER SURGICAL DISEASES WILL TRY TO ANSWER YOUR QUESTIONS.
ANYTHING PARTICULAR ABOUT THIS DISEASE WILL BE EXPLAINED TO PATIENTS.
PLEASE DONLOAD THE FOLLOWING INFORMATION IN THE FORM OF QUESTIONS. ANSWER THEM AND SEND IT TO DR SACHIN KUBER AT :- drskuber@gmail.com
please SELECT-COPY-PASTE THIS FORM. FILL IT OUT AND SEND IT TO DR SACHIN KUBER
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FORM FOR HERNIA PATIENTS
PLEASE FILL OUT THIS FORM SO WE BETTER UNDERSTAND YOU TO HELP
1. NAME:-
2. AGE:-
3. ADDRESS:-
4. PHONE/MOBILE:-
5. SEX:-
6. COMPLAINTS:-
7. LOCATION OF SWELLING OF HERNIA:-
8. DURATION OF ITS PRESENCE:-
9. ONSET TIME OF SYMPTOMS:-
10. SUFFERRING SINCE:-
11. PAINFUL OR PAINLESS:-
12. RESTRICT YOUR ACTIVITY- YES/NO
13. VOMITING-YES/NO
14. FEVER-YES/NO
15. URINARY PROBLEMS-Y/N
16. BOWEL PROBLEMS-Y/N
17. CONSTIPATION-Y/N
18. SMOKING:
19. ALCOHOL:
20. WEIGHT LIFTING:-OCCASIONAL/ALWAYS
21. DIABETES:-Y/N
22. HYPERTENSION:-Y/N
23. HEART DISEASE:-Y/N
24. ANY ILLNESS IN PAST:-Y/N
25. HISTORY OF ANY SURGERY IN PAST:- Y/N
26. NAME OF SURGERY:-
27. ANY CURRENT AILMENT:-
28. PAIN AT HERNIA SITE:-Y/N
29. SWELLING REDUCES ON ITS OWN:-Y/N
30. SWELLING DOES NOT REDUCE:-Y/N
31. DRAGGING TYPE OF PAIN AT HERNIA SITE:-Y/N
PLEASE ANSWER THESE SIMPLE QUESTION AND DR SACHIN KUBER WILL BE HAPPY TO HELP.
