Case register - عيادة الدكتور هشام محمد السواح

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Home
Case register
About us
Services
Clinic
- Clinic
- E-Clinic
English
- العربية

Home
Case register
About us
Services
Clinic
- Clinic
- E-Clinic
English
- العربية

Case registerMohammed2018-02-20T04:57:16+00:00

Step 1 of 4

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Name*
Prefix First Middle Last
Date of birth*
Gender*
Nationality
Phone*
Email*
Enter Email Confirm Email
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Profile picture
Accepted file types: jpeg, png, jpg.
This photo is important for the doctor to remember the patient

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Smoking*
- Yes
- No
- Casual
Drinking
- Yes
- No
- Casual
Weight (Km)
Please enter a number from 20 to 200.
Tall (Cm)
Please enter a number from 20 to 200.
BMI
Please enter a number from 20 to 50.
Body mass index

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Anemia*
- No
- Yes
Haemophilia*
- No
- Yes
Viral disease*
- No
- Yes
Viral type*
- B
- C
- HIV
Diabetes*
- No
- Yes
Hypertention*
- No
- Yes
Other diseases

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Complain*
For how long?*
- Less than a month
- 1-6 months
- 6-12 months
- 1-3 years
- Over 3 years
Heartburn ?*
Severity*
- 1
- 2
- 3
- 4
- 5
min: 1 - Max: 5
For how long?*
- Less than a month
- 1-6 months
- 6-12 months
- 1-3 years
- Over 3 years
Chest pain ?*
Severity*
- 1
- 2
- 3
- 4
- 5
min: 1 - Max: 5
For how long?*
- Less than a month
- 1-6 months
- 6-12 months
- 1-3 years
- Over 3 years
Epigastric pain ?*
Severity*
- 1
- 2
- 3
- 4
- 5
min: 1 - Max: 5
For how long?*
- Less than a month
- 1-6 months
- 6-12 months
- 1-3 years
- Over 3 years
Food regurgitation ?*
Severity*
- 1
- 2
- 3
- 4
- 5
min: 1 - Max: 5
For how long?*
- Less than a month
- 1-6 months
- 6-12 months
- 1-3 years
- Over 3 years
Nausea ?*
Severity*
- 1
- 2
- 3
- 4
- 5
min: 1 - Max: 5
For how long?*
- Less than a month
- 1-6 months
- 6-12 months
- 1-3 years
- Over 3 years
Vomiting ?*
Severity*
- 1
- 2
- 3
- 4
- 5
min: 1 - Max: 5
For how long?*
- Less than a month
- 1-6 months
- 6-12 months
- 1-3 years
- Over 3 years
Hiccough ?*
Severity*
- 1
- 2
- 3
- 4
- 5
min: 1 - Max: 5
For how long?*
- Less than a month
- 1-6 months
- 6-12 months
- 1-3 years
- Over 3 years
Belching ?*
Severity*
- 1
- 2
- 3
- 4
- 5
min: 1 - Max: 5
For how long?*
- Less than a month
- 1-6 months
- 6-12 months
- 1-3 years
- Over 3 years
Eructation ?*
Severity*
- 1
- 2
- 3
- 4
- 5
min: 1 - Max: 5
For how long?*
- Less than a month
- 1-6 months
- 6-12 months
- 1-3 years
- Over 3 years
Throat clearing ?*
Severity*
- 1
- 2
- 3
- 4
- 5
min: 1 - Max: 5
For how long?*
- Less than a month
- 1-6 months
- 6-12 months
- 1-3 years
- Over 3 years
Hoarseness of Voice ?*
Severity*
- 1
- 2
- 3
- 4
- 5
min: 1 - Max: 5
For how long?*
- Less than a month
- 1-6 months
- 6-12 months
- 1-3 years
- Over 3 years
Dry mouth ?*
Severity*
- 1
- 2
- 3
- 4
- 5
min: 1 - Max: 5
For how long?*
- Less than a month
- 1-6 months
- 6-12 months
- 1-3 years
- Over 3 years
Cough ?*
Severity*
- 1
- 2
- 3
- 4
- 5
min: 1 - Max: 5
For how long?*
- Less than a month
- 1-6 months
- 6-12 months
- 1-3 years
- Over 3 years
Food related*
Sleep related*
Swallowing Difficulty ?*
Level*
which Type of food?*
Severity*
- 1
- 2
- 3
- 4
- 5
min: 1 - Max: 5
For how long?*
- Less than a month
- 1-6 months
- 6-12 months
- 1-3 years
- Over 3 years
Halitosis ?*
Sinusitis ?*
Ear ache ?*
Chest Problems ?*
Choose Chest Problems*
Severity*
- 1
- 2
- 3
- 4
- 5
min: 1 - Max: 5
For how long?*
- Less than a month
- 1-6 months
- 6-12 months
- 1-3 years
- Over 3 years
Heart Problem?*
Type Heart Problem*
Fever ?*
Abdominal pain ?*
Abdominal distension ?*
Constipation ?*
Diarrhea ?*
Black stool ?*
Dyspnea ?*
Anxiety ?*
Investigation done ?*
Choose*
Medication taken*
Medication*
Therapeutic procedure done before?*
Therapeutic procedure*
Number of Balloon dilatation*
Please enter a number from 1 to 5.
Number of savary dilation*
Please enter a number from 1 to 5.
Type other therapeutic procedure*
Operations done before do not belong to the esophagus?
Type operations ?*
Describe other complain*
Onset*
Number of motions*
Bristol stool chart*
Choose one from the chart in this link https://upload.wikimedia.org/wikipedia/commons/9/9e/BristolStoolChart.png
Family History*
Colonic problem*
Problem*
Choose at least one problem
Fever*
Abdominal pain*
Low water intake*
Thyroid problem*
Problem*
Post diet*
Post laxative abuse*
Post pregnancy*
Post medication*
Type medication*
Post overweight*
Post weight loss*
Weight loss*
Post surgery*
Surgery*
Anal problem*
Problem*
Blood in stool*
Bleeding Type*
Neurological deficit*
Describe your Neurological problem*
Psychological problem*
Describe your psychological problem*
Vertebral column defect*
Describe your vertebral column defect*
Investigation done*
Investigation*
Received treatment*
Received treatment*
- Medication
- Biofeedback
- Alternative medicine
Medication*
Number of Biofeedback Sessions?*
Please enter a number from 1 to 20.
Alternative Medicine*
Radiology and analysis files
Drop files here or
Accepted file types: jpeg, png, jpg, pdf, doc, docx.
Comments
This field is for validation purposes and should be left unchanged.

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Egypt – Cairo – Heliopolis – El-Horya St. 85

Phone: 0020226900595 - 00201005399636

Mobile: 00201001724408 - 00201283499449 - 00201211611186

Email: [email protected]

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