Create new patient
Basic Details
1
Additional Details
2
PERSONAL DETAILS
Full name
*
Please provide full name
Patient Id
Gender
*
Male
Female
Other
Age
*
Type
Years
Months
Days
Birth date
CONTACT DETAILS
Mobile
*
Referred By
BODY METRICS
Blood group
Select blood group
O+
A+
B+
AB+
A-
O-
B-
AB-
Height Cm(s)
Weight (kg)
BMI = 0
*
FIELDS ARE MANDATORY
Next
CONTACT DETAILS
Locality
Address
City
Country
Email Id
HABITS
Alcohol
Yes
No
Full name
Full name
Full name
Tobacco
Yes
No
Full name
Full name
Full name
FAMILY HISTORY
Diabetes
Yes
No
Hypertension
Yes
No
Heart Disease
Yes
No
PERSONAL HISTORY
Diabetes
Yes
No
Hypertension
Yes
No
Heart Disease
Yes
No
OB HISTORY
Full name
Full name
Full name
Full name
Surgery
Menarch (Age in years)
Menstural Cycle
Regular
Irregular
Duration of Bleeding (in Days)
Bleeding type
Select bleed type
High
Regular
Low
Bleeding/Spotting between periods
Yes
No
Bleeding/Spotting After intercouse
Yes
No
Pain type
LMP Date
Pregnant
Gestational age
E.D.D
ALLERGY INFORMATION
Envorimental
Dust allergy
Dust allergy
Dust allergy
Food
Dust allergy
Dust allergy
Dust allergy
Drug
Dust allergy
Dust allergy
Dust allergy
Any other
Dust allergy
Dust allergy
Dust allergy
Finish