"KILL FLU EARLY, SAVE LIFE" WORLDWIDE CAMPAIGN
Quantum ProCytronics MediClinic
(A Unit of PabCyte Life Sciences Pvt. Ltd)
COLD & FLU DIVISION
Dr. Vikram Pabreja
M.B.B.S. — Consultant Physician
DMC 108534 · HMC 23900 · Member: IMA, USA/Canada
drvikrampabreja.in
Patient Details
Mobile Number
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Name
*
Age
Sex
Select…
Male
Female
Other
Visit Date
Time
Patient Presented with Complaint of (C/o)
History
History of Travel
Yes
No
History of Tobacco / Alcohol / Recreational Substance
Yes
No
Fever
Fever with Chills
Shivering
Fever Without Chills
Eye, ENT & Upper Airways
Pink / Red Eyes / Watery / Itchy / Burning
Painful Eyes
Swollen Eyes
Heavy Eyes
Cough
Dry
Expectoration
Yellow / Green / Blood / Blood Clots
Blocked Ear
Earache
Ear Discharge
Loss of Smell
Stuffy Nose
Running Nose
Nasal Congestion
Post Nasal Drip
Feeling Cold
Sneezing
Heavy Head / Headache
Itchy / Harsh Throat
Pain / Difficulty in Throat while Swallowing
Can’t Speak
Change in Voice
Mucous from Nose or Mouth
Sweating
Mouth Breathing
Others (Eye, ENT & Upper Airways)
Lower Airways
Wheeze
Pain in Ribs
Chest Pain
SOB
Chest Congestion
Deep Cough / Chest Discomfort
Others (Lower Airways)
Abdominal
Nausea
Vomiting
Diarrhea
Loss of Appetite
Cramp / Pain Abdomen
Altered Bowel Movements
Not Formed Stools
Bleeding / Dry Piles
Bloating
Belching
Loss of Taste
Gas
Black Stools
Others (Abdominal)
General / Others
Dizziness
Difficulty in Arousal
Unsteadiness
Fainting
Fatigue / Lethargy
Burning Behind Chest
Severe Weakness
Skin Rashes
Loss of Energy
No Urine x 8 hrs (Anuria)
Less Urine (Oliguria)
24 Hr. UOP
Body Ache
Difficulty in Sleeping
Nocturnal Wheeze
Epilepsy / Seizures
Others (General / Others)
COVID-19 Details
H/o Covid 19
Yes
No
No. of Episodes
One
Two
More than 2
Recovery Time
Vaccination Status
Flu Vaccine
Pneumococcal Vaccine
COVID Vaccine
COVID Vaccine Doses
1st Dose
2nd Dose
Booster
"KILL FLU EARLY, SAVE LIFE" WORLDWIDE CAMPAIGN
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