रुग्ण पूर्व तपासणी नोंदणी Head of Family: Address: District : Pune Taluka : Haveli Pin Code 411001411002411003411004411005411006411007411008411009411010411011411012411013411014411015411016411017411018411019411020411021411022411023411024411025411026411027411028411029411030411031411032411033411034411035411036411037411038411039411040411041411042411043411044411045411046411047411048411049411050411051411052411053411054411055411056411057411058411059411060411061411062411063411064411065411066411067411068411069411070411071411072411073411074411075411076411077411078411079411080411081411082411083411084411085411086411087411088411089411090411091411092411093411094411095411096411097411098411099 Mobile No.: Date of Birth: 1) Family Member: Date of Birth: Mobile No.: Health Status: HealthyRequired Health check up 2) Family Member: Date of Birth: Mobile No.: Health Status: HealthyRequired Health check up 3) Family Member: Date of Birth: Mobile No.: Health Status: HealthyRequired Health check up 4) Family Member: Date of Birth: Mobile No.: Health Status: HealthyRequired Health check up Health Checkup:Bypass surgeryAngioplastyHeart disordersBone graftingGastric and intestinal surgeryKidney transplantDiseases and surgeries of childrenBrain disordersCancerSkin diseasesDialysisPulmonary disorders of infantsKidney diseasePlastic surgeryEye surgerySerious injury in accidentEar-Nose-ThroatRespiratory disorders and tuberculosisDental diseaseAmniotic sac surgerySurgeries of eardrumsGynecology / PediatricsBone surgerySpine surgeryGeneral SurgeryMental healthGeneral MedicineObesityAyush Ration Card:Yellow Ration CardSaffron Ration CardWhite Ration CardDon't HaveOther Issue Patient Pre-Screening Registration Patient Full Name: Patient Health History Background: Main Disease: Nearest Tertiary Care Facility:Aundh villageKasturba / Indira ColonyBopodiKhadkiWadarwadiGokhale NagarMulla RoadShivajinagar GavthanSangamwadiYerwadaN.Ta. WadiSanjay Gandhi Laman Tanda, PashanPashan GavthanSutarwadiPadal Vasti and Aundh RoadSomeshwar WadiPatil EstatePMC Colony, Wakdewadi, ShivajinagarRange HillsSaprasKhairewadiKhilareWastiDr. Babasaheb Ambedkar Colony, Aundh1202, Pulachi Wadi Other Msg.(optional) HEALTH CHECK UP(Screening-1) Chief Complaint Investigation Advice/Finding Korean Diagnosis Refer to Department Height (Cm) Wait (Kg) BMI=(I5/(H5/100)/H5/100)) BP(mmHg) History of Jaundice YESNO Oral Cancer Signs YESNO Anti-HTN drugs YESNO Anti DM drugs YESNO Subject: Wanted To Add New Fresh Form Click Button Below: Add Another / New Form Entry
