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(no id) · K. Selvam
Edited 20 Aug 2026, 06:22 IST
form 241 of 1542 · 1542 reviewed, 0 left
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No ID
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Batch 2
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B
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C
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D
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The scanned form
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
Soodamaipuram, alagappapuram, KKDI
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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
Present
Notes
Diabetes
she having DM for Past 20 years
Hypertension
She having hypertension for past 20 years
Asthma
Heart Disease
Thyroid Disorders
for past 20 year
Others
Previous Surgeries
She undervent hemorhoiclectoney
Allergies
Smoking History
Alcohol Use
Family History
Screening Vitals
Height
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Weight
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Blood Pressure (BP)
? Check
SPO2
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Pulse
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Temperature
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Screening Tests
Test
Done
Result
Cbg
156
Hba1C
8.2
Haemoglobin
12.2
Thyroid
Ecg
Done
Xray
Bmd
Done
Biothesiometry
Done
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)
foot irritation , joint pain disbetic Nemopathy
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Diagnosis
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ICD codes
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Treatment Advice
Prescription Advice
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Referral: to Dr.
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Referral Department
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