Jaide Demo

1 - In the last 7 days, how often have you been staying in bed?

Little (only at bedtime)Medium (I need to rest after completing my tasks)A lot (I only leave the bed to come for treatment)

1 - In the last 7 days, have you been passing more gas?

Not at allLittleMediumA lot

1 - In the last 7 days, have you had loose or liquid stools?

Not once a dayOnce a dayTwice a dayMore than twice a day

1 - In the last 7 days, have you had stomach pain (abdominal pain)?

Not once a dayOnce a dayTwice a dayMore than twice a day

1 - In the last 7 days, have you felt pain or burning when urinating?

Not once a dayOnce a dayTwice a dayMore than twice a day

1 - Have you noticed any difference in your skin color?

There's no difference in the skinThe skin is redThe skin is darkenedI have a wound on the skin

1 - In the last 7 days, how often have you felt nauseous?

Not at allOnce a dayTwice a dayMore than twice a day

1 - In the last 7 days, how often have you vomited?

Not at allOnce a dayTwice a dayMore than twice a day

Patient Intake Form