Patient Registration Form

Clinic name: ______________________________

Date: ______________

OP No.: ______________

व्यक्तिगत जानकारी

Patient Name / मरीज़ का नाम

Age / आयु

Sex / लिंग

Phone / फ़ोन

Address / पता

Occupation / व्यवसाय

Chief Complaint / मुख्य शिकायत

Medical History / चिकित्सा इतिहास

Tick any that apply

Jaundice / पीलिया

High Blood Pressure / उच्च रक्तचाप

Heart Diseases / हृदय रोग

Bleeding Disorders / रक्तस्राव विकार

Hemophilia / हीमोफीलिया

Allergy / एलर्जी

Anemia / एनीमिया (रक्ताल्पता)

Fits / मिर्गी (दौरे)

Asthma / RS Disorders / दमा / श्वसन रोग

Thyroid / थायराइड

Diabetes / मधुमेह (शुगर)

Kidney Diseases / गुर्दे की बीमारी

Pregnancy / Lactating / गर्भावस्था / स्तनपान

Allergies or other conditions

Consent / सहमति

I hereby give consent to the doctor and those under their professional supervision to prescribe and perform whatever treatment, operation, anesthesia or other procedure which is deemed necessary or appropriate and mutually agreed upon.

Patient Signature / मरीज़ के हस्ताक्षर

Date

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Free Patient Registration Form in Hindi and English

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