RHAZES PATIENT REGISTRATION FORM

RHAZES PATIENT REGISTRATION FORM

This form is to be filled by Rhazes Healthcare Professional Provider (RHPP).
Professional Healthcare Provider*
*Title / Name / Designation
Professional Healthcare Provider Email*
example@example.com
Date / Tarikh*

MonthDayYear
Date
Time / Masa*

Hour Minutes

AM/PM Option
Patient ID (State your Patient ID_For form Retrival)
SERVICES PROVIDED / PERKHIDMATAN YANG DITAWARKAN*

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*

High blood pressure/Darah tinggiDiabetes/Kencing manisHeart disease/Sakit jantungHigh cholesterol/Kolestrol tinggiKidney disease/Penyakit buah pinggangMigraine/MigrainLiver disease/Penyakit hatiMental 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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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

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

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

ReferralMedication SlipFollow Up (Next Booking Date / Booked in advanced)NilOther
Please specify the Next Booking Date

MonthDayYear
Date
RHAZES TELEHEALTH INTERNATIONAL SDN BHD Website : www.rhazesconsult.com Email : admin@rhazestelehealth.com / Whats'App +6013-393 8042
Should be Empty:

Patient Demographic Profile / Profile Demografik Pesakit