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260802I035 · S. Shamugaralli
Edited 11 Aug 2026, 11:26 IST
form 1219 of 1542 · 1542 reviewed, 0 left
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Patient Information
Full Name
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Gender
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Marital Status
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Mobile Number
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Address
Sangaran 56, Pananthoppu, santhaipettai , karaikudi
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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
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Notes
Diabetes
Hypertension
Asthma
Heart Disease
Thyroid Disorders
Others
Previous Surgeries
Allergies
Smoking History
Alcohol Use
Family History
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
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Result
Cbg
161
Hba1C
Haemoglobin
Thyroid
Ecg
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Xray
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Purpose of Visit / Department Needed
General Medicine
General Surgery
OrthoPaedics
Dermatology
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ENT
OBG
Pediatrics
Oncology
Others
Ophthalmology
Diabetology
Cardiology
Neurology
Psychiatry
Urology
Nephrology
Gastroenterology
Pulmonology
Doctor's Consultation
Chief Complaints (C/O)
Abdominal Pain, Breathing difficulty
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Diagnosis
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ICD codes
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Treatment Advice
Prescription Advice
Syp. Antacid 10m. 1-1- Tab. pan BD Chymoral Zincovit kal nD.Tab. P 1-0-0 0.1
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Referral: to Dr.
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Referral Department
Dene
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