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260802H002 · Karthikeyanm
Edited 19 Aug 2026, 17:12 IST
form 1120 of 1542 · 1542 reviewed, 0 left
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No ID
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Batch 2
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A
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B
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C
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D
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E
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F
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G
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H
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I
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J
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K
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L
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The scanned form
Patient Information
Full Name
✎ Edited
Gender
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Marital Status
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Mobile Number
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Address
9-A, 18padiNagar, Kkdi
✎ Edited
Register Number / UHID
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Age
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Father / Spouse Name
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Blood Group
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Aadhar Number
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Insurance Name/No
– Blank
Medical History
Condition
Present
Notes
Diabetes
?
Hypertension
?
hypertension for past 10 years. he taken medication for Bp T.Telmiccen 20mg
Asthma
?
previous lung infection he taken treatment
Heart Disease
Thyroid Disorders
Others
Previous Surgeries
?
he had a previous histroy of knee surgery
Allergies
Smoking History
Alcohol Use
?
occationally
Family History
?
he had a family history of hypertension & diabetics
Screening Vitals
Height
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Weight
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Blood Pressure (BP)
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SPO2
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Pulse
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Temperature
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Screening Tests
Test
Done
Result
Cbg
?
132
Hba1C
Haemoglobin
Thyroid
Ecg
Wave inversion V1
Xray
Bmd
Biothesiometry
Purpose of Visit / Department Needed
General Medicine
General Surgery
OrthoPaedics
Dermatology
Dental
Physiotherapy
ENT
OBG
Pediatrics
Oncology
Others
Ophthalmology
Diabetology
Cardiology
Neurology
Psychiatry
Urology
Nephrology
Gastroenterology
Pulmonology
Doctor's Consultation
Chief Complaints (C/O)
Came for regular checkup c/o abdonimal pain, gastritis
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Diagnosis
DM & HT
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ICD codes
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Treatment Advice
Prescription Advice
– Blank
Referral: to Dr.
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Referral Department
ENT
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