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                                                                 Hiranandani Hospital

                                                                          Your Family Hospital
                                                              A NABH Accredited Hospital

                          (National Accreditation Board for Hospitals & Healthcare Providers. An initiative of Quality Council of India)
Nov 3, 2019 - Nov 2. 2021                                         ISO 9001:2015 CERTIFIED

                                                  OPD - INITIAL ASSESSMENT FORM                                                               Sr. No.


                                (PLEASE NOTE : THIS FORM TO BE FILLED IN CAPITAL LETTERS ONLY)                                                      28/02/23

                                                                                                                                     Date :                                         it

                                          MR. RISHI Aquiand

          Patient's Name                                                                                             (Surname)
                                              (First name)


          Address                                                          (Postal Address / Email / Mobile)
                                                                                                                                                                                     1


          TMR. No
                                                                   (If no TMR no, Pls. mentioned address)

                                     49              M
                                                                                    fullw.wuf                             Nutritional Assessment
           Age / Sex
                                                                                                                           Height:
           Clinical Notes :                                                                                                                 834
                                                                                                                           Weight                                (kg)

         Gomfelserr Worter Antakung 1                                            Tal GLYCICON (SO)                         Built:

           (3.4 1doar(das)
                                                                                                         1312 3d.        Signs of Malnutrition: Yes / No

                                                                                                                          Mention if Yes:
          Beta-cell frenchin - 30%                                            POL LUPIST (50/500)                                                              1-135-140.
                                                                                                                                     125/80
                                                                                                            :04
          Insulin Seraitinty 536 2                                                                                                                         PN85-160.

                                      ( MEGLYN)                         2 to Ineglyn (100g).
                                                                                           VI
                                                                                                                                                                         (70-140)
                                                                             The LDAP1 - 10mg

                                                                                                                                                           Tel - 4.6

                                                                               Ve AT DIATILAL 010.                                                         AABS 228

                                                                                 Ja Gabarre: 4013 001 6 5ml                                                    So PSA- 1.1

                                                                                   Te EVION-CC OUT -3041
                                                                                                                                                           SINON- 116.0


              History & Diagnosis :
                                                                                 et 14 Viteall "
                                                                                                                                                               1:135-181.
                                                                                                               ./min ente/10/
                                                                                                                                16 10 mg                       KDL-135

                                                                                                                                                               116 All- 7.5


                                                                                                               Dr. S. M. Bylakuda

              Care Plan :                                                                                                                                                                 33
                                                                                                                           MD, POPS, ICH MICA (U.S.A.)
                                                                                                               Consultant Phyniftya & Diabolologist
                                                                                                                             REG.       36. 36914
                                                                                                                           LIL AVAT JIOSPITAL.
                                                                                                                  L. H. HIRANANDANI HOSPITAL


                Drug Allergy


                Current medication : (Drug patient takes in routine)

{'clinic_pharmacy_details': {'clinic_pharmacy_name': 'Your Family Hospital', 'clinic_pharmacy_address': 'NA', 'clinic_pharmacy_city': 'NA', 'clinic_pharmacy_pincode': 'NA'}, 'doctor_details': {'doctor_name': 'Dr. S. M. Bylakuda', 'doctor_qualifications': 'MD, POPS, ICH MICA (U.S.A.)', 'doctor_registration_number': 'REG. 36. 36914'}, 'patient_details': {'patient_name': 'MR. RISHI Aquiand'}, 'prescription_details': {'date_of_doctor_consultation': '28/02/23'}, 'procedure': {'chief_complaints_diagnosis': 'Clinical Notes : Gomfelserr Worter Antakung 1'}, 'medicine_details': [{'medicine_name': 'Tal GLYCICON (SO)', 'medicine_dosage': '1-135-140.', 'medicine_frequency': 'NA', 'course_duration': 'NA'}, {'medicine_name': 'Beta-cell frenchin - 30%', 'medicine_dosage': 'NA', 'medicine_frequency': 'NA', 'course_duration': 'NA'}, {'medicine_name': 'POL LUPIST (50/500)', 'medicine_dosage': 'NA', 'medicine_frequency': 'NA', 'course_duration': 'NA'}, {'medicine_name': 'Insulin Seraitinty 536 2', 'medicine_dosage': 'NA', 'medicine_frequency': 'NA', 'course_duration': 'NA'}, {'medicine_name': 'Ineglyn (100g)', 'medicine_dosage': 'NA', 'medicine_frequency': 'NA', 'course_duration': 'NA'}, {'medicine_name': 'The LDAP1 - 10mg', 'medicine_dosage': '(70-140)', 'medicine_frequency': 'NA', 'course_duration': 'NA'}, {'medicine_name': 'Tel - 4.6', 'medicine_dosage': 'NA', 'medicine_frequency': 'NA', 'course_duration': 'NA'}, {'medicine_name': 'Ve AT DIATILAL 010', 'medicine_dosage': 'NA', 'medicine_frequency': 'NA', 'course_duration': 'NA'}, {'medicine_name': 'Ja Gabarre: 4013 001 6 5ml', 'medicine_dosage': 'NA', 'medicine_frequency': 'NA', 'course_duration': 'NA'}, {'medicine_name': 'Te EVION-CC OUT -3041', 'medicine_dosage': 'NA', 'medicine_frequency': 'NA', 'course_duration': 'NA'}, {'medicine_name': 'SINON- 116.0', 'medicine_dosage': 'NA', 'medicine_frequency': 'NA', 'course_duration': 'NA'}, {'medicine_name': 'et 14 Viteall', 'medicine_dosage': '1:135-181.', 'medicine_frequency': 'NA', 'course_duration': 'NA'}, {'medicine_name': 'KDL-135', 'medicine_dosage': 'NA', 'medicine_frequency': 'NA', 'course_duration': 'NA'}, {'medicine_name': '116 All- 7.5', 'medicine_dosage': 'NA', 'medicine_frequency': 'NA', 'course_duration': 'NA'}], 'lab_test_details': {'lab_test_names': 'NA', 'procedure_request': 'NA'}}