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260802C095 · Muthulakshnu
Edited 18 Aug 2026, 11:40 IST
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No ID
✓ 4
Batch 2
✓ 401
A
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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
✎ Edited
Gender
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Marital Status
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Mobile Number
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Address
illupakudi,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
Present
Notes
Diabetes
?
Hypertension
?
Asthma
?
Heart Disease
?
Thyroid Disorders
?
Others
ulcer complaint for past 1 year
Previous Surgeries
?
Allergies
?
Smoking History
?
Alcohol Use
?
Family History
family histoy of HT and DM ,cancer
Screening Vitals
Height
– Blank
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
Done
Result
Cbg
?
115
Hba1C
Haemoglobin
Thyroid
Ecg
Done
Xray
knee
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)
Throte Pain, knee Pain
✎ Edited
Diagnosis
OAT Knee
✎ Edited
ICD codes
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Treatment Advice
Prescription Advice
pan-40 A celoplous. nillngel
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Referral: to Dr.
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Referral Department
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