Visit Date

Ticket No:

Visitor:

Blood Group:

Gate Pass:

Blood Pressure:

Heart Rate:

Temperature:

SpO2:

Epilepsy:

Diabetes:

If you have any medical condition(s) or illness, please provide details: Yes No

Do you have any allergies with Medicine or Chemical restrictions? Yes No

Are you on any Medication at the moment? Yes No

Do you have any Open wound/ Rash / Skin Reactions on your body? Yes No

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Doctor's Comments

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