🩺 Record Detail
Patient Info
Name: Unknown
Age: Unknown
Date: 2025-09-25 12:07:14
Transcript
Doctor: So, I will just start the live recording and will show you how it functions. So, let's say patient is a case of CAD having diabetes mellitus since last 5 years taking medicines Ecosprin and Telmekind. Patient is having a patient is having a high blood pressure since last 15 days asked to follow up after 1 month.
Clinical Notes
General Check-Up Template
Patient Information
- Patient Name: _________
- Age / DOB: _________
- Gender: _________
- Contact Number: _________
- Date of Visit: _________
Chief Complaint / Reason for Visit
High blood pressure
Medical History
Chronic Illnesses (if any):
- Diabetes
- Hypertension
- Asthma
- Thyroid Disorder
- Other: Coronary Artery Disease (CAD)
Surgeries / Hospitalizations:
Current Medications:
- Ecosprin
- Telmekind
Allergies (Drugs/Food):
Lifestyle Details
- Smoking: ☐ Yes ☐ No
- Alcohol Consumption: ☐ Yes ☐ No
- Exercise Routine: ☐ Regular ☐ Occasional ☐ Sedentary
- Diet: ☐ Balanced ☐ High-Fat ☐ Low-Carb ☐ Vegetarian ☐ Other: _
Vital Signs
| Vital | Reading |
| Blood Pressure | ____ mmHg |
| Pulse Rate | ____ bpm |
| Temperature | ____ °C |
| Respiratory Rate | ____ breaths/min |
| Oxygen Saturation (SpO2) | ____ % |
| Weight | ____ kg |
| Height | ____ cm |
| BMI | __________ |
General Physical Examination
- Appearance: ☐ Well ☐ Pale ☐ Fatigued
- Eyes: ☐ Normal ☐ Redness ☐ Jaundice
- Ears/Nose/Throat: ☐ Normal ☐ Infection
- Skin: ☐ Normal ☐ Rash ☐ Dryness
- Heart Sounds: ☐ Normal ☐ Murmur
- Lung Sounds: ☐ Clear ☐ Wheezing ☐ Crackles
- Abdomen: ☐ Soft ☐ Tender ☐ Distended
- Extremities: ☐ Normal ☐ Swollen
- Neurological: ☐ Alert ☐ Oriented ☐ Other: _ __________
Investigations (If Needed)
- ☐ Blood Test
- ☐ Urine Test
- ☐ ECG
- ☐ Chest X-Ray
- ☐ Others: _____ __________
Assessment / Diagnosis
Treatment / Medications Prescribed
Doctor's Advice & Recommendations
- ☐ Healthy Diet
- ☐ Regular Exercise
- ☐ Hydration
- ☐ Stress Management
- ☐ Follow-up Visit on: ___