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Ref No: 10000

Date: date

ePRESCRIPTION

Patient Name:

Age: years

Gender:

Blood Pressure: / mmHg

Pulse Rate: /min

Weight: kg

Temperature: F

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Medication To be Taken:

ID	Drug Name	Dosage	Frequency	Duration

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Next Visit:

........................................

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First Name	Last Name	Gender

First Name	Last Name	Gender

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ePRESCRIPTION

Patient Name:

Age: years

Gender:

Blood Pressure: / mmHg

Pulse Rate: /min

Weight: kg

Temperature: F

Notes / Investigation / Diagnosis:

Medication To be Taken:

Tests to be Carried Out:

Next Visit:

........................................

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HbA1c:

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uMicroAlbumin:

UFR:

Temperature:

Cholesterol:

Tg:

Pulse:

LDL-Cholesterol:

Hb:

Date	Weight	Height	Temp(F)	Pulse	BP1	BP2	Waist	FBS	2hr PPG	HbA1c	Creatinine	24Hr Urine-Protein	uMicroAlbumin	UFR	SE	Cholestorol	hdIC	IdIC	tg	Hb

Name:	Age:	Gender:
Blood Pressure:	Plus Rate:	Wt:
Temp:

Notes/Investigation/Diagnosis

Medication to be taken

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01/01/2017

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01/01/2017

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