Patient Case History & Treatment Documentation

Complete all sections accurately. Fields marked * are required.

1

Patient Basic Information

Full Name *

Mobile Number *

Age *

Gender *

City / Location

Occupation

Date of Consultation *

Case ID / UHID

2

Chief Complaint

Main Problem / Chief Complaint *

Symptoms (Select all that apply)

Pain Swelling Bleeding Discharge Difficulty in Movement Fever Numbness

Symptom Details

3

Duration of Problem

Approximate Duration

Few Days Few Weeks Few Months More than 1 Year

Exact Duration

4

History of Present Illness

How Did the Problem Start?

Gradual or Sudden Onset?

Previous Treatment Taken?

Yes No

Treatment Details

5

Past Medical History

Pre-existing Conditions

Diabetes Hypertension Heart Disease Asthma Thyroid Kidney Disease Cancer

Other Details

6

Previous Surgical History

Any Previous Surgery?

Yes No

Surgery Name

Year

Hospital

Outcome

7

Family History

Similar Problem in Family?

Yes No

Family History Details

8

Clinical Examination Findings

Doctor Examination Notes

Vital Parameters

Blood Pressure

Pulse Rate

Weight

Height

BMI

9

Investigations & Reports

X-Ray

Pre-Treatment X-Ray

📁

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JPG, PNG, PDF supported

Post-Treatment X-Ray

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JPG, PNG, PDF supported

Doctor Remarks

MRI

Pre-Treatment MRI

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JPG, PNG, PDF supported

Post-Treatment MRI

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JPG, PNG, PDF supported

Doctor Remarks

CT Scan

Pre-Treatment CT Scan

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JPG, PNG, PDF supported

Post-Treatment CT Scan

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JPG, PNG, PDF supported

Doctor Remarks

Ultrasound

Pre-Treatment Ultrasound

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JPG, PNG, PDF supported

Post-Treatment Ultrasound

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JPG, PNG, PDF supported

Doctor Remarks

Blood Reports

Report Types

CBC LFT KFT Sugar

Upload Blood Reports

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Doctor Remarks

10

Clinical Images

Before Treatment Photos

🖼️

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JPG, PNG supported

Doctor Notes

During Procedure Photos

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JPG, PNG supported

Doctor Notes

After Treatment Photos

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JPG, PNG supported

Doctor Notes

11

Diagnosis

Final Diagnosis *

ICD Code (Optional)

12

Treatment Plan

Recommended Treatment

13

Why This Treatment Was Selected?

Doctor's Explanation

Alternative Options Considered

14

Procedure / Surgery Details

Procedure Name

Date of Procedure

Operating Doctor

Duration

Anaesthesia Type

Implants Used

Complications (If Any)

15

Post Treatment Outcome

Immediate Outcome

Patient Improvement

Excellent Good Average Poor

Doctor Comments

16

Follow-up Details

1st Follow-up

Date

Findings

2nd Follow-up

Date

Findings

3rd Follow-up

Date

Findings

17

Patient Testimonial

Patient Feedback

Rating

★ ★ ★ ★ ★

Video Testimonial

Yes No

Upload Testimonial Video (Optional)

🎥

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MP4, MOV, AVI supported

18

Doctor Case Summary

Case Title

Short Summary (100–150 words)

Detailed Summary (300–500 words)

19

Educational Value

Learning Point 1

Learning Point 2

Learning Point 3

Learning Point 4

Learning Point 5

20

Consent & Authorization

Patient Consents For *

Medical Records Images Videos Website Publication Social Media Publication Educational Use

Patient Name (Signature Acknowledgement)

Doctor Name (Signature)

Consent Date

Final Upload Checklist

Patient Photo Before Images After Images X-Ray MRI CT Scan Blood Reports Prescription Consent Form Testimonial Video Follow-up Reports Final Case Summary

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