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(no id) · Mr. Ganesha Perumal
Edited 13 Aug 2026, 14:16 IST
form 355 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
3 Aayiram Kannudayal street Kalavai pott
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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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Medical History
Condition
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Diabetes
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He having DM for past 3 years, he is on medicine
Hypertension
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He having HTN for past 3 years, he is on medicine
Asthma
Heart Disease
Thyroid Disorders
Others
Previous Surgeries
Allergies
Smoking History
Alcohol Use
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once in while
Family History
Screening Vitals
Height
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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
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Cbg
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Hba1C
Haemoglobin
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Ecg
Xray
ls-spine
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Biothesiometry
Purpose of Visit / Department Needed
General Medicine
General Surgery
OrthoPaedics
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OBG
Pediatrics
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Ophthalmology
Diabetology
Cardiology
Neurology
Psychiatry
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Doctor's Consultation
Chief Complaints (C/O)
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Diagnosis
Lumbar Spondysis
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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
ortho
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