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260802B275 · Naciyappan
Edited 18 Aug 2026, 16:36 IST
form 676 of 1542 · 1542 reviewed, 0 left
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Q9
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Q10
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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
✓ 190
The scanned form
Patient Information
Full Name
✎ Edited
Gender
✓ Verified
Marital Status
✓ Verified
Mobile Number
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Address
Karaikudi
✓ Verified
Register Number / UHID
? Check
Age
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Father / Spouse Name
✓ Verified
Blood Group
✓ Verified
Aadhar Number
✎ Edited
Insurance Name/No
– Blank
Medical History
Condition
Present
Notes
Diabetes
?
since 25 years he is taking medicine
Hypertension
?
since 25 years he is taking the medicine
Asthma
wheezing (6months)
Heart Disease
Thyroid Disorders
?
Others
Previous Surgeries
hip ball replacement , hand plate
Allergies
?
Smoking History
?
Alcohol Use
?
Family History
Screening Vitals
Height
– Blank
Weight
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Blood Pressure (BP)
✓ Verified
SPO2
✓ Verified
Pulse
✎ Edited
Temperature
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Screening Tests
Test
Done
Result
Cbg
124
Hba1C
Haemoglobin
Done
Thyroid
Ecg
Xray
Done
Bmd
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)
C/o numbers, pain in lower extremrties
✎ Edited
Diagnosis
DM 1-17,fatigue
✎ Edited
ICD codes
✓ Verified
Treatment Advice
Prescription Advice
Inj Reneplus -1. pregardine 0-0-1Methylcobalmin 0-0-1 Pan 40 DSR 0-0-1
✎ Edited
Referral: to Dr.
– Blank
Referral Department
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! Not read
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