TAHIR HEART INSTITUTE
  SERVING HUMANITY !
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PATIENT REGISTRATION FORM

 GENERAL INFORMATION:
Full Name:
S/O, D/O, W/O:
Age / Date of Birth:
Sex:
Martial Status:
Phone:
Mobile:
Occupation:
C.N.I.C /Passport No:
Email Address:
Postal Address:
City:
Country:
Who told you about Tahir Heart Institute?:
Please Explain:
Your Diagnostics / Complaints:
Symptoms Duration :
Seeking for:
MEDICAL DATA
(Please give details if Yes):
Are you having High Blood Pressure / Hypertension ?
 
Are you diabetic ?
 
Have you ever suffered from a heart disease e.g. Angina/Heart Attack ?
 
Are you suffering from T.B. / Have you ever had it ?
 
Are you asthmatic / Do you have difficulty breathing ?
 
Any disease involving kidneys ?
 
Have you ever had Jaundice / Hepatitis ?
 
Have you ever had a Stroke / paralysis ?
 
Do you smoke / have you been smoking in the past? Number of cigarettes / day ?
 
Is your Cholesterol level higher than normal ?
 
Are you overweight ?
 
Do you have a family history of high Blood pressure/Diabetes/Heart disease or Stroke ?
 
Have you had any surgeries in the past ?
 
Your blood group (if known):
 
Any history of Blood transfusions in the past ?
 
Any known allergies to drugs/foods etc. ?
 
Any other relevant information you believe would be helpful?
 
CONSENT FOR TREATMENT
I hereby willingly consent to treatment at Tahir Heart Institute. This consent covers any treatment regarding medications, anesthesia, surgical procedures, nursing and other care given in this facility.