Dr. Chaiti Phulwaria

Patient Information

Patient Name *

Age

Sex

Contact No.

Date of Visit

Weight (kg)

Referred By

Address / City

Allergies / Contraindications

OBG Details & Obstetric History

LMP

Gravida

Para

Abortions

Live Births

EDD

Blood Group

Rh Status

Antenatal Findings

Gynaec / Menstrual History

Online Consultation

Platform

Duration

Telemedicine Consent

Vitals

BP (mmHg)

Pulse (/min)

Temp (°F)

SpO₂ (%)

Height (cm)

BMI

History & Examination

Chief Complaints

Past Medical / Surgical History

Examination Findings

Diagnosis

Provisional / Final Diagnosis

Differential Diagnosis

Investigations & OBG Metrics

Enter results if available. Leave blank if not done. Advised tests will appear on the prescription.

🩸 Haematology

Hb (g/dL)

Haematocrit (%)

WBC (×10³/µL)

Platelets (×10³)

Blood Group

Rh Antibodies

Peripheral Smear

Serum Ferritin

🧪 Biochemistry

FBS (mg/dL)

PPBS (mg/dL)

HbA1c (%)

GCT (mg/dL)

TSH (mIU/L)

T3 / T4

S. Creatinine

Uric Acid

S. Calcium (mg/dL)

Vit D (ng/mL)

Vit B12 (pg/mL)

Folic Acid (ng/mL)

🔬 Urine Analysis

Urine Albumin

Urine Sugar

Pus Cells

Culture / Sensitivity

🧬 Serology / Infection Screen

HIV

VDRL (Syphilis)

HBsAg

HCV

🔊 Obstetric Ultrasound

USG Type

GA by USG (weeks)

EFW (grams)

Fetal Presentation

Placenta

AFI (cm)

Cervical Length (mm)

NT (mm)

USG Notes / Findings

💓 CTG / NST

CTG Result

FHR Baseline (/min)

Variability

📋 Investigations Advised (will appear on prescription)

Quick add: ANC Panel | USG | GDM Screen | Urine

℞ Medications

#	Drug / Brand	Dose	Route	Frequency	Duration	Qty	Instructions

Advice, Follow-up & Plan

General Advice / Diet / Lifestyle

Specific OBG Advice

Follow-up Instructions

Next Visit Date

Referral To

Sick Leave (Days)

Emergency Warning Signs to Watch

Who's prescribing today?

All Prescriptions

Ready to prescribe

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