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260802L104 · Rameleeshmi
Edited 11 Aug 2026, 12:42 IST
form 1391 of 1542 · 1542 reviewed, 0 left
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Q9
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No ID
✓ 4
Batch 2
✓ 401
A
✓ 134
B
✓ 151
C
✓ 75
D
✓ 78
E
✓ 80
F
✓ 95
G
✓ 99
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
✓ Verified
Marital Status
✓ Verified
Mobile Number
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Address
sri ram nagar
✎ Edited
Register Number / UHID
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Age
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Father / Spouse Name
✓ Verified
Blood Group
✓ Verified
Aadhar Number
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Insurance Name/No
– Blank
Medical History
Condition
Present
Notes
Diabetes
?
Dm past 10years under medication
Hypertension
?
HT past 10years under medication
Asthma
Breathing difficulty
Heart Disease
?
Thyroid Disorders
?
thyrom 88 mg
Others
?
thyroid problem past 10 years
Previous Surgeries
hysterectomy done before 20 years
Allergies
?
Smoking History
?
Alcohol Use
?
Family History
?
family history of Dm& HT
Screening Vitals
Height
– Blank
Weight
✓ Verified
Blood Pressure (BP)
✓ Verified
SPO2
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Pulse
✓ Verified
Temperature
– Blank
Screening Tests
Test
Done
Result
Cbg
236
Hba1C
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)
Eye Problem,watery eye, pooling of eye
✎ Edited
Diagnosis
– Blank
ICD codes
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Treatment Advice
Prescription Advice
Zincovit 1-0-0 Rantac 10. Amocillin 50mg calcicum 102. Tab. Aclc
✎ Edited
Referral: to Dr.
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Referral Department
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