1st Visit Details Form

Step 1 of 3 – Patient Details

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Select Patient

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Patient Entry ID

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Doctor on Duty

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Old Entry ID

Name of Patient

Registration Number

Temperature (°C)

Pulse (bpm)

Height (cm)

Systolic (mmHg)

Diastolic (mmHg)

Spo2 (%)

Weight (kg)

BMI

Chief Complaint

General Examination

Preliminary Diagnosis

History

Plan of Action

Select Test/Procedure 1

Cost 1

Add Test/Procedure 2

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Notes on Test/Procedure 1

Select Test/Procedure 2

Cost 2

Add Test/Procedure 3

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Notes on Test/Procedure 1

Select Test/Procedure 3

Cost 3

Add Test/Procedure 4

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Notes on Test/Procedure 3

Select Test/Procedure 4

Cost 4

Add Test/Procedure 4

Click to Add

Notes on Test/Procedure 4

Select Test/Procedure 5

Cost 5

Notes on Test/Procedure 5

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Summary of Lab/Procedure Recommendations

Grand Total (Tshs)