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Patient Assessment Form
Patient Assessment Form
Patient Details
Name
Mobile Number
Height
Weight (in KG)
Gender
Male
Female
Other
Hospital Details
Hospital Name
Location Of The Hospital
Bed No./Detail
Relative's Name
Relative's Mobile Number
Consultant Doctor
Allergy Known
Current Location of The Patient
ICU
Ward
Home
For Comorbidities
Kindly hold Control to select
Diabetes Mellitus
Hypertension
All Cardiac Diseases (Congenital/Acute/Chronic)
All Lung Diseases including Asthma
All Neurological Conditions
Developmental Disorders
All Renal Diseases
All Liver Diseases
Inflammatory Bowel Disease
Any Cancer or on treatment for cancer
All Genetic disorders
Congenital Metabolic Disorders
Obesity- BMI >30 kg/m2
Endocrine Disorders
Rheumatological Disorders
Persons on Immunosuppressive therapy
Auto Immune Diseases
Hematological conditions- Sickle Cell Disease/ Bone marrow failure/ Aplastic Anemia/ Thalassemia Major
Primary Immunodeficiency Diseases/ HIV infection
Poly Cystic Ovarian Disease (PCOD)
Differently abled individuals
Any organ transplant -including Hematopoietic stem cell transplant: Recipient/On waitlist/Donor
Any other conditions which merits vaccination as per the certifying doctor
Bed Sore
Yes
No
If Yes, Bed Sore Area
Skin Status
Fall Risk
High
Moderate
Low
Bed Ridden
Yes
No
Remarks
Food to be avoided (Eg. Pot, Rich Food Avoided in Renal Patient)
If you are human, leave this field blank.
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