260 lines
10 KiB
HTML
260 lines
10 KiB
HTML
<link rel="stylesheet" href="/bahmni_config/openmrs/apps/registration/admissionFormLayout/css/bootstrap.min.css"/>
|
||
<link rel="stylesheet" href="/bahmni_config/openmrs/apps/registration/admissionFormLayout/css/style.css"/>
|
||
<div class="container">
|
||
<div class="row" style="margin-top:5px">
|
||
<div class="col-md-8">
|
||
<span>Patient ID / Reg. No.</span>
|
||
<span>....................................................................................................................................</span>
|
||
</div>
|
||
<div class="col-md-4">
|
||
<span>Cabin/Ward</span>
|
||
<span>...........................................................................</span>
|
||
</div>
|
||
</div>
|
||
|
||
<div class="row" style="margin-top:5px">
|
||
<div class="col-md-8">
|
||
<span>Staff / Health Card ID</span>
|
||
<span>..................................................................................................................................</span>
|
||
</div>
|
||
<div class="col-md-4">
|
||
<span>Bed No.</span>
|
||
<span>...................................................................................</span>
|
||
</div>
|
||
</div>
|
||
<div class="row" style="margin-top:5px">
|
||
<div class="col-md-8">
|
||
<span>Patient Name</span>
|
||
<span>..................................................................................................................................................</span>
|
||
</div>
|
||
<div class="col-md-4">
|
||
<span>Sex</span>
|
||
<span>............................................................................................</span>
|
||
</div>
|
||
</div>
|
||
<div class="row" style="margin-top:5px">
|
||
<div class="col-md-8">
|
||
<span>Age</span>
|
||
<span>......................................................................................................................................................................</span>
|
||
</div>
|
||
<div class="col-md-4">
|
||
<span>Blood Group</span>
|
||
<span>.........................................................................</span>
|
||
</div>
|
||
</div>
|
||
<div class="row" style="margin-top:5px">
|
||
<div class="col-md-8">
|
||
<span>Occupation</span>
|
||
<span>.......................................................................................................................................................</span>
|
||
</div>
|
||
<div class="col-md-4">
|
||
<span>Contact No</span>
|
||
<span>............................................................................</span>
|
||
</div>
|
||
</div>
|
||
|
||
<div class="row" style="margin-top:5px">
|
||
<div class="col-md-12">
|
||
<span>Fathers/Husband Name</span>
|
||
<span>..............................................................................................................................</span>
|
||
</div>
|
||
</div>
|
||
<div class="row" style="margin-top:5px">
|
||
<div class="col-md-12">
|
||
<span>Mothers Name</span>
|
||
<span>...............................................................................................................................................</span>
|
||
</div>
|
||
</div>
|
||
|
||
|
||
<div class="row" style="margin-top:15px">
|
||
<div class="col-md-4">
|
||
<span>Present Adress</span>
|
||
</div>
|
||
<div class="col-md-4">
|
||
<span>Village</span>
|
||
<span>...................................................</span>
|
||
</div>
|
||
<div class="col-md-4">
|
||
<span>P.O</span>
|
||
<span>................................................................</span>
|
||
</div>
|
||
</div>
|
||
|
||
<div class="row" style="margin-top:5px">
|
||
<div class="col-md-4">
|
||
<span></span>
|
||
</div>
|
||
<div class="col-md-4">
|
||
<span>P.S</span>
|
||
<span>..........................................................</span>
|
||
</div>
|
||
<div class="col-md-4">
|
||
<span>District</span>
|
||
<span>.........................................................</span>
|
||
</div>
|
||
</div>
|
||
|
||
<div class="row" style="margin-top:15px">
|
||
<div class="col-md-4">
|
||
<span>Permanent Address</span>
|
||
</div>
|
||
<div class="col-md-4">
|
||
<span>Village</span>
|
||
<span>...................................................</span>
|
||
</div>
|
||
<div class="col-md-4">
|
||
<span>P.O</span>
|
||
<span>................................................................</span>
|
||
</div>
|
||
</div>
|
||
|
||
<div class="row" style="margin-top:5px">
|
||
<div class="col-md-4">
|
||
<span></span>
|
||
</div>
|
||
<div class="col-md-4">
|
||
<span>P.S</span>
|
||
<span>..........................................................</span>
|
||
</div>
|
||
<div class="col-md-4">
|
||
<span>District</span>
|
||
<span>.........................................................</span>
|
||
</div>
|
||
</div>
|
||
<div class="row" style="margin-top:10px">
|
||
<div class="col-md-12">
|
||
<span><b>Emergency Contact Name</b> : </span>
|
||
<span>....................................................................................................................</span>
|
||
</div>
|
||
</div>
|
||
<div class="row" style="margin-top:5px">
|
||
<div class="col-md-12">
|
||
<span>Phone : </span>
|
||
<span>................................................................................................................................................................</span>
|
||
</div>
|
||
</div>
|
||
<div class="row" style="margin-top:5px">
|
||
<div class="col-md-12">
|
||
<span>Diagnosis : </span>
|
||
<span>.........................................................................................................................................................</span>
|
||
</div>
|
||
</div>
|
||
|
||
<div class="row" style="margin-top:5px">
|
||
<div class="col-md-12">
|
||
<span>...............................................................................................................................................................................................................................................................................................................................</span>
|
||
</div>
|
||
</div>
|
||
<div class="row" style="margin-top:5px">
|
||
<div class="col-md-12">
|
||
<span>Attending Doctor’s Name</span>
|
||
<span>..........................................................................................................................................................................................................................................................................</span>
|
||
</div>
|
||
</div>
|
||
<div class="row" style="margin-top:5px">
|
||
<div class="col-md-8">
|
||
<span>Consultant Name : </span>
|
||
<span>.........................................................................................................................................</span>
|
||
</div>
|
||
<div class="col-md-4">
|
||
<span>(Emergency) : </span>
|
||
<span>.......................................................................</span>
|
||
</div>
|
||
</div>
|
||
<div class="row" style="margin-top:5px">
|
||
<div class="col-md-8">
|
||
<span>Date of Admission : </span>
|
||
<span>........................................................................................................................................</span>
|
||
</div>
|
||
<div class="col-md-4">
|
||
<span>Time : </span>
|
||
<span>......................................................................................</span>
|
||
</div>
|
||
</div>
|
||
<div class="row" style="margin-top:5px">
|
||
<div class="col-md-8">
|
||
<span>Date of Discharge : </span>
|
||
<span>........................................................................................................................................</span>
|
||
</div>
|
||
<div class="col-md-4">
|
||
<span>Time : </span>
|
||
<span>......................................................................................</span>
|
||
</div>
|
||
</div>
|
||
<div class="row" style="margin-top:5px">
|
||
<div class="col-md-8">
|
||
<span>Date of Surgery : </span>
|
||
<span>.............................................................................................................................................</span>
|
||
</div>
|
||
<div class="col-md-4">
|
||
<span>Time : </span>
|
||
<span>......................................................................................</span>
|
||
</div>
|
||
</div>
|
||
|
||
<div class="row" style="margin-top:20px">
|
||
<div class="col-md-8">
|
||
<table style="width:50%;>
|
||
<tr>
|
||
<th colspan=">Mode of Discharge</th>
|
||
</tr>
|
||
<tr>
|
||
<td></td>
|
||
</tr>
|
||
</table>
|
||
</div>
|
||
<div class="col-md-4">
|
||
<span><b>Signature : </b></span>
|
||
<span>..........................................................................</span>
|
||
</div>
|
||
</div>
|
||
<div class="row" style="margin-top:15px">
|
||
<div class="col-md-8">
|
||
|
||
<span></span>
|
||
</div>
|
||
<div class="col-md-4">
|
||
<span>Name : </span>
|
||
<span>...................................................................................</span>
|
||
</div>
|
||
</div>
|
||
<div class="row" style="margin-top:5px">
|
||
<div class="col-md-8">
|
||
<span></span>
|
||
</div>
|
||
<div class="col-md-4">
|
||
<span>Date : </span>
|
||
<span>......................................................................................</span>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
|
||
|
||
|
||
|
||
|
||
|
||
|
||
|
||
|
||
|
||
|
||
|
||
|
||
|
||
|
||
|
||
|
||
|
||
|
||
|
||
|
||
|
||
|
||
|
||
|
||
|
||
|
||
|