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Kidney Stone Disease

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Kidney Stone Disease

Please fill in the form completely.

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Patient Information

Full Name *

Age *

Gender *

What is your complaint?

What are your complaints?

I do not have any

Side Pain

High Fever

Other Complaints

Write your story about your illness.

When did your symptoms start?

Please inform us about the history of your illness:

Your additional diseases:

Previous surgeries (if any):

Please state the medications you take on a regular basis (with doses)

Do any first or second degree relatives have kidney stone disease?

If yes, please indicate:

Have you had any previous treatment for this disease?

Did you receive any treatments for this disease before?

I did not receive any treatments for kidney stone disease before

ESWL (using shock waves to break a kidney stone)

Ureteroscopic Laser Lithotripsy

Percutaneous Nephrolithotomy (PNL)

Open Surgery to remove kidney stones

Left Kidney

Right Kidney

Left Kidney

Right Kidney

Left Kidney

Right Kidney

Left Kidney

Right Kidney

Treatment Year

Imaging (Radiology) Reports

Urinary Tract Ultrasonography

Non-contrast CT of the Urinary Tract

IVP - Intravenous Pyelogram

Complete CT scan of the Abdomen

Complete MRI scan of the Abdomen

Laboratory Examinations

Hemogram (Complete Blood Count) Report

Biochemistry Report

I have read and understood the Information and Consent Text regarding the Provision of Remote Healthcare Services and hereby accept its terms.*

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