Registration
Particulars ( of Patient ) :
Name………………………………………………Gender………………………………
Date of birth ……………………………………………Age…………………………….
Place of birth……………………………Time of Birth…………………………………..
Weight………………Complexion……………. ………………Height …………………
Complete Address ……………………………………………………………...............
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Contact Numbers : ………………………………………………………………………..
Prognosis / diagnosis of the latest medical
expert ……………………………………
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Final verdict / opinion ( if any ) of the latest medical expert : ……………………….
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Description of illness from patient’s
perspective : .....……………...…………………. ………………………………………………………………………………………………. ……………………………………………………………………………………………….
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Brief
History of ailment(s) and ongoing treatment : …………….…………………….. ……………………………………………………………………………………………….
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Drugs taken :
…………………………… ………………………………………………… …………………………………………………………………………………………….…. ……………………………………………………………………………………………….. Family history of ailments ( if any ) :
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Personal
information ( Habitual & Preferences ) :
Smoking
( ), Drinking ( ), Tobacco
chewing ( ), Paan Masala ( ), Khainee
( ), Drugs ( ), Vegan
( ), Vegetarian ( ), Junk Food
( ), Non
– Vegetarian : mutton( ),Chicken ( ), Fish ( ), Beaf ( ), Egg
( )
Quantity
& Frequency : …….………………………………………………………………… Duration
: …………………………………………………………………………………………
Dislikes
or Allergic to :………………………………………………………………………..
Important
:
‘Agreement /
Declaration’ submitted
by him / her along with this form.
commencement of the treatment requires minimum of 72 hours.
KSCT
or the Dispenser of the medicine is not responsible for the loss of or the
delay
in the delivery of medicines - postal or couriered articles sent by the
Dispenser
of the medicine or by any designated person on behalf of KSCT .
Ailments
(suffering) : ( To be
filled by the KSCT personnel. )
( KSCT - A ) –
………………………………..………………..……………...........................
( KSCT - B ) – ………………………………..………………..……………........................... ( KSCT – C ) – ………………………………..………………..……………........................... ( KSCT – D ) – ………………………………..………………..……………........................... ( KSCT – E ) – ………………………………..………………..……………...........................
Name : …………………………………………………………………………........................
Signature : …………………………………… ………………………………………………….
Place : ……………………......………..Date :
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The patient should sign a declaration accordingly on the form of Mandatory
After getting samples of body fluids from the patients, the
preparations for
Dispatch of medicines
cannot be claimed as a matter of right.