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260802I004 · Bala Musuganns
Edited 11 Aug 2026, 10:26 IST
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No ID
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B
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The scanned form
Patient Information
Full Name
✎ Edited
Gender
? Check
Marital Status
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Mobile Number
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Address
89, MGR street, kalavaipottal, karaikudi
✎ 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
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Medical History
Condition
Present
Notes
Diabetes
Having DM for past 8 years & under medication
Hypertension
Asthma
Heart Disease
Thyroid Disorders
Others
Previous Surgeries
He is underwent Appendectony.
Allergies
Smoking History
Habit of smoking.
Alcohol Use
habit of drinking alcohol
Family History
Screening Vitals
Height
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Weight
✓ Verified
Blood Pressure (BP)
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SPO2
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Pulse
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Temperature
– Blank
Screening Tests
Test
Done
Result
Cbg
Hba1C
8
Haemoglobin
Thyroid
Ecg
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)
Abdominal Pain
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Diagnosis
– Blank
ICD codes
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Treatment Advice
Prescription Advice
Cetirizine Tab. Teunscart an cy Amlodipine
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Referral: to Dr.
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Referral Department
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! Not read
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