RHAZES PATIENT REGISTRATION FORM
This form is to be filled by Rhazes Healthcare Professional Provider (RHPP).
Consultant Optometrist / Community Optometrist Details
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*Title / Name / Designation
Consultant Email
*
example@example.com
Date / Tarikh
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Month
-
Day
Year
Date
Time / Masa
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Hour Minutes
AM
PM
AM/PM Option
Patient ID
SERVICES PROVIDED / PERKHIDMATAN YANG DITAWARKAN
*
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Patient Demographic Profile / Profile Demografik Pesakit
Patient Name / Nama Pesakit
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Patient Email
*
example@example.com
Patient Mobile Phone Number / No Mobile Pesakit
*
Gender / JantinaType a question
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Please Select
Male / Lelaki
Female / Perempuan
Birthday
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Month
-
Day
Year
Date Picker Icon
Today
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Month
-
Day
Year
Date Picker Icon
Age - days
Age - Years
Status
Single / Bujang
Married / Berkahwin
Occupation / Pekerjaan
Nationality
Malaysian
Non Citizen
Permenent Resident
Race / Bangsa
Malay
Chinese
Indian
Bumiputra Sabah / Sarawak
Others
Religion / Agama
Islam
Christian
Hindu
Buddhist
Other
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PATIENT ADDITIONAL INFORMATION / MAKLUMAT TAMBAHAN PESAKIT
1. Guardian's Name (applicable for patients under the age of 18) / Nama Penjaga (untuk kanak-kanak bawah 18 tahun) . If Yes, Please specify the his/her name / Jika Ya, Sila nyatakan namanya ...
2. Do you have any medication, food and herbs allergies? / Adakah anda mempunyai sebarang alahan pada ubatan / makanan / herba? If Yes, Please Specify. Jika Ya, Sila Nyatakan.
3. Please state any diseases experienced by any of the family members if applicable. / Sila nyatakan penyakit yang dihadapi oleh mana-mana ahli keluarga jika berkenaan.
MEDICAL & MEDICATION HISTORY / SEJARAH KESIHATAN & MEDIKASI
Patient's Medical History / Sejarah Perubatan Pesakit
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High blood pressure/Darah tinggi
Diabetes/Kencing manis
Heart disease/Sakit jantung
High cholesterol/Kolestrol tinggi
Kidney disease/Penyakit buah pinggang
Migraine/Migrain
Liver disease/Penyakit hati
Mental illness/Masalah mental / Stress / Tekanan / Depression
Other Diseases/ Penyakit Lain
Patient's Medication History / Sejarah Medikasi Pesakit
Upload any relevant medical Information here if required ie; prescription slip, discharge summary
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If you're a patient, please submit the form now. The remaining pages will be filled in by your consultant. Thank you!
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SOAP GUIDELINES
This referral will be addressed to a Healthcare Professionals who provides a particular service. It will explain the medical reason why the patient is being referred to the Healthcare Professionals, and it will also include any relevant medical history, including allergies and medications.
SUBJECTIVE (S) : Chief Complaints“Subjective” experiences, personal views or feelings of a patient. Present a problem reported by the patient/why the patient is presenting.
SUBJECTIVE (S) : History of Present Illness (HPI) - Summary of recent history contributing to the CC
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OBJECTIVE (O)
OBJECTIVE (O) : Current Medication List
"Objective" Data encounter from patient
OBJECTIVE (O) : Vital Signs - BP, HR, RR, Wt, Ht, BMI, Temp, and O2.
"Objective" Data encounter from patient
OBJECTIVE (O) : Physical Exam Findings - observations and results of any exams done
"Objective" Data encounter from patient
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ASSESSMENT (A)
This section is where the clinician assimilates all the information they have obtained from the Subjective and Objective areas and applies it to standard practice as defined by evidence-based medicine.
ASSESSMENT (A) : Assessment and therapy justification for each problem (Initial Assessment, Treatment Goals, Treatment Options and Justification)
ASSESSMENT (A) : State the problem and differential diagnosis (diagnosis from most likely to least likely)
PLAN OF ACTION (P)
Detail the need for additional testing and consultation with other clinicians to address the patient's illnesses. It also addresses any additional steps being taken to treat the patient. This section helps future physicians understand what needs to be done next.
NEXT PLAN OF ACTION
Referral
Medication Slip
Follow Up (Next Booking Date / Booked in advanced)
Nil
Other
Please specify the Next Booking Date
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Month
-
Day
Year
Date
RHAZES TELEHEALTH @ RHAZES CONSULTANCY SERVICES SDN BHDWebsite : www.rhazesconsult.com / Email : rhazestelepharmacy@gmail.com / Whats'App 013-393 8042
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