Patient Intake — Ministry of AYUSH & ABDM

Patient Demographics

Please verify your personal details and contact information.

Full Name *

Age (Years) *

Gender *

Male / पुरुष / পুরুষ Female / महिला / মহিলা Other

Mobile Phone Number *

Emergency Contact Phone

Aadhaar Number (UIDAI - 12 digits)

Masked for privacy compliance

Ayushman / ABHA ID (14 digits)

Ayushman Scheme Category / Coverage

Chief Complaint

What is the primary reason for your hospital visit today?

Select Primary Symptoms (Tap all that apply):

Chest / Heart / Breathing

Chest Pain / Pressure Urgent

Shortness of Breath

Heart Racing / Palpitations

Fever / Infection / Chills

High Fever (>101°F)

Persistent Cough / Cold

Chills / Night Sweats

Stomach / Digestion

Abdominal / Stomach Pain

Vomiting / Nausea

Loose Stools / Diarrhea

Headache / Neurological

Severe Headache / Migraine

Dizziness / Vertigo / Fainting

Sudden Weakness / Slurred Speech Urgent

Joints / Bones / Injury

Joint / Knee Pain

Severe Back / Spine Pain

Sprain / Fracture / Swelling

How long have you had these symptoms?

Today (< 24 Hours)

1 to 3 Days

1 to 2 Weeks

Over 1 Month (Chronic)

Describe in your own words (or use Hold to Speak):

History of Present Illness (HPI)

Tell us more about how the symptoms started and their intensity.

How did the symptoms begin?

Sudden onset (Started abruptly)

Gradual onset (Slowly built up)

Is the condition worsening or stable?

Worsening over time

Stable / Constant

Comes and goes (Intermittent)

Pain / Discomfort Severity Level: 5 / 10

😊 1 (Mild)😐 5 (Moderate)😫 8 (Severe)🚨 10 (Unbearable)

Past Medical History

Do you have any existing chronic illnesses or past surgeries?

High Blood Pressure (Hypertension)

Diabetes (Sugar)

Asthma / Breathing Issues / COPD

Heart Disease / Prior Heart Attack

Kidney Disease / Dialysis

Thyroid Disorder

Past Surgery / Hospitalization

Allergies

Do you have any known allergic reactions to medications or foods?

Essential Safety Information: Knowing drug allergies prevents dangerous prescription reactions.

No Known Drug Allergies (NKDA)

Penicillin / Antibiotics Allergy

Painkillers (NSAIDs / Aspirin) Allergy

Food Allergy (Peanuts, Eggs, Seafood)

Other Allergy (Specify)

Current Medications

Are you currently taking any prescription, OTC, or AYUSH/Herbal medicines?

I am not taking any medicines currently

Daily BP / Diabetes Medications

Blood Thinners / Heart Medicines

Ayurvedic / Homeopathic / Herbal Remedies

Family History

Does anyone in your direct family (parents, siblings) have major conditions?

Early Heart Disease / Stroke

Diabetes

High Blood Pressure

Cancer

None / Not sure

Personal & Lifestyle History

Select lifestyle habits relevant to your health (Optional).

Tobacco / Bidi / Cigarette Smoker

Alcohol Consumption

Vegetarian Diet

Non-Vegetarian Diet

Have prior paper prescriptions or lab reports?

You can upload photos of your old records before meeting the doctor.

Add Documents