                                                                                                                                                                                           Tel. No. 9416136295,9416158162
                                                                                                            SAI HOSPITAL
                                                                                                                                                                                           EMail saihospitalhisar@gmail.com
                                                                                                      NABH ACCREDITED                                                             OPD TIMINGS :08:00 AM to 06:00 PM
                                                                                          Near HUDA Office, Dabra Road, Hisar                                                      ON SUNDAY : 10:00 AM to 01:00 PM
                  SATHOSPITAL                                                                   Patient Assessment Sheet                                                                     (On availability of doctor)

                                                                                                                                                                                               Serial No. : 1
            OPD No.                               : 3635                                                                              Date                   : 11/May/2023

           Patient Name                           : Mst. JIGGAR                                                                      Age / Sex : 5 Years / Male
           Consultant                             : Dr. Kapil Singla                                                                 Guardian Name : S/O PARLHAD
           Department                            : ENT Head & Neck                                                                   UHID No. : 91760
                                                                                                                                                                             ( ·· ····· ···· ·· ··· ·· ···
          Address                                 GANGWA 9812280598                                                                  Amount : RS. 300.00
                                                                                                                                                                               ····· ··)


       Vitals : BP                                                        Weight ..........                                                                                                        .. Temp.
                                                                                                               .... Height .......                         ...... HR
       Allergy : Drug .....                                                 . Smoking                                 Alcohol                          -Tobacco ..           ... Pregnancy(Married Females)
       Disease : COPD ........... CVS.                                                .. Hepato/GI.                                                                                                             LDM.
                                                                                                                     ... Neuro ...                             ... Renal.      ...., Thyroid.
       Nutritional Screening:                                Under Nourished                                                                               [] Over Weight                       Obese
                                                                                                                               Normal
       ··· ·· ······· ·· ···· ·········· ·· ···· · ···· ··· ··· ··· · ··· ···· ···· ···· ··· ······· ·· ··· ······ ···· ·· ··· ····· ···· ··· ······ ····· / ·······
       / ······ ·· ···· ··· ··· ····· ···· ···


         Patient                                  ..
         Complaints




         History of                           :
         Present Illness




         Provisional                                                                                                                                          Gelx w
                                              :
         Diagnosis




        Investigations
        Required



                20% duay




                                                                  079




                                          079



 Follow up After                                           Days/ SOS

····· ···· ··· ······ ····· ·· ······· ···· ··· ···· ···

                                                                                                                                                                                                    Dr. Kapil Singla
Not Valid for MLC Purpose
Prescribed medicines are only suggestions, patient is free to choose any reliable                                                                                                                   MBBS - MS (ENT)
generic/brand of their choice with exactly the same content                                                                                                                                            HN - 4664




A Dataman Software (0512) 2376505.2317191                                                                                                                                    Printed on 11/May/2023 7:13

{'clinic_pharmacy_details': {'clinic_pharmacy_name': 'SAI HOSPITAL', 'clinic_pharmacy_address': 'Near HUDA Office, Dabra Road, Hisar', 'clinic_pharmacy_city': 'Hisar', 'clinic_pharmacy_pincode': 'NA'}, 'doctor_details': {'doctor_name': 'Dr. Kapil Singla', 'doctor_qualifications': 'MBBS - MS (ENT)', 'doctor_registration_number': 'HN - 4664'}, 'patient_details': {'patient_name': 'Mst. JIGGAR'}, 'prescription_details': {'date_of_doctor_consultation': '11/May/2023'}, 'procedure': {'chief_complaints_diagnosis': 'COPD, sore throat'}, 'medicine_details': [{'medicine_name': 'PAN 40', 'medicine_dosage': '1-0-1', 'medicine_frequency': 'Morning and Night', 'course_duration': '7 days'}, {'medicine_name': 'Azithromycin', 'medicine_dosage': '500 mg', 'medicine_frequency': '1-0-0', 'course_duration': '5 days'}, {'medicine_name': 'Paracetamol', 'medicine_dosage': '250 mg', 'medicine_frequency': '1-0-1', 'course_duration': '3 days'}], 'lab_test_details': {'lab_test_names': 'NA', 'procedure_request': 'NA'}}