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Health Risk Assessment
Digestive Disorder
1
2
3
Pick one of the following:
I am experiencing gastrointestinal disease symptoms and they affect my daily life.
I am experiencing gastrointestinal disease symptoms but they do not affect my daily life.
Please choose the symptom you have been experiencing:
Regurgitation of food or fluid
Heartburn: A sensation of burning in your chest.
Dysphagia: Facing trouble in swallowing
Chest pain even though you have no heart diseases.
Felt a lump in your throat.
Persistent throat clearing, hoarseness of voice, and a sore throat.
Excessive burping.
Burning abdominal pain and discomfort.
Feeling full shortly after starting to eat.
Difficulty in passage of stools, constipation, hard stools, difficulty with bowel movements and requiring medication to facilitate emptying your bowel
Felt bloated with a swollen or tight stomach.
Incontinence; felt a loss of control over bowel function, leading to unintentional leakage of urine or feces.
None of the above.
Are these symptoms of abdominal discomfort or burning sensation accompanied by alterations in bowel movements, such as changes in their appearance or frequency?
Yes
No
Frequent nausea & vomiting sensation?
Yes
No
Have you experienced gastrointestinal symptoms persistently for more than 3 months?
Yes
No
Have you undergone any treatment for gastrointestinal symptoms in the past?
Yes
No
Choose a symptom that you currently experience:
Frequent vomiting with (or without) blood.
Stool accompanied by dark or fresh blood.
History of stomach or colon cancer within the family
Sudden weight loss.
Anemia due to iron deficiency (pale complexion, experiencing faintness).
I have no such symptoms.
Acknowledgements and Certification
I hereby certify that I have read and acknowledged the entire Hospital's
Privacy Policy.
I certify that the personal data filled in this form is true, correct and current. In case I fill in on behalf of other persons, I confirm that I have obtained their consent or have a legal right to disclose their personal data to the Hospital.
Consent
I grant my consent to the Hospital to collect, analyze, process, use and disclose my personal data and send me information about products, services, advertisements, or promotional campaigns that will benefit me through all channels I have provided to the hospital.
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