Date

Register Client Register Client Register Client Yes No

Doctor Prescription Doctor Prescription Yes No

Doctor Name

Hospital Name

Sample No

C Time

R Time

Patient Name

Patient Id

Age

Date Of Birth

Gender Select Gender Male Female Other

Mobile No

Patient Address

Village/Town

District

Pincode

Others

Clinical Symptoms :
Heart disease Chronic renal disease Diabetes Hypertension

Other Symptoms :
FBS PPBS HbA1c CBC UREA CREATININE LIPIDS TFT URINE RE Hb Gr Rh BP Nalam A Nalam B Nalam C Nalam D