Confidential Medical Record — Not for General Distribution

Workplace Illness Management

Shastho Link

Ref: —
Date: —
Time: —

Patient Medical Record—

Attending Professional

Doctor / Staff Name—

BMDC Reg. No.—

Designation—

Facility / Factory—

Patient Demographics

Patient Name—

Mobile Number—

Age—

Sex—

Height (cm)—

Weight (kg)—

Blood Pressure—

Bed Time—

Wake-up Time—

Sleep Schedule—

Work Profile

Job Role / Designation—

Total Experience—

Home Distance—

Job Nature—

Hrs / Day—

Hrs / Week—

Years in Current Role—

Job / Work Area—

Environmental & Risk Indicators

Chemical / Dust Exposure—

Noise Exposure—

Physical Strain—

Temperature Condition—

Clinical Presentation

Primary Symptom(s)—

Secondary Symptom(s)—

Duration—

Severity—

Type of Illness—

Happened Earlier?—

Consultation Taken?—

Medication Ongoing?—

Operation History?—

Operation Details—

Provisional Diagnosis—

Chronic Disease(s)—

Drinking / Smoking Habit—

Family Disease History—

Doctor's Assessment

Suggested Diagnostic Tests—

Recommended Medicines—

Food Recommendation—

Exercise Recommendation—

Follow-up Recommended—

Additional Notes—

Doctor's Name & Signature

Signature & Stamp

Received By — HR / Line Supervisor

Name: _________________________________

Signature & Date

Who is filling this form?

Select your role to load the appropriate sections

Medical Assistant

Fill in patient details, work profile and environmental risk information

Sections 1 · 2 · 3

Doctor / Physician

Complete clinical presentation, assessment and attending professional details

Sections 4 · 5 · 6

Print Prescriptions

View completed prescriptions queue and print or download PDF for any patient

Print · Download PDF

Management Dashboard

Illness trends, job area risk analysis, disease breakdown and action plan

Daily · Monthly · Yearly

My Health File

Patients can view their visits, diagnosis, medicines and prescriptions

Mobile Number Login

Medical Assistant — Fill sections 1, 2, 3 then submit. A Record ID will be generated to hand to the doctor.

Patient Demographics

Patient Name *

Mobile Number (Serial / Contact)

Age * (years)

Sex *

Height * (cm)

Weight * (kg)

Blood Pressure * (mmHg)

Bed Time

Wake-up Time

Environmental & Risk Indicators

Exposure to Chemicals / Dust

Noise Exposure Level

Physical Strain Level

Temperature Condition

Sections 1–3 will be saved · Record ID will be generated for the doctor

Patient Record Submitted

Sections 1–3 saved to Google Sheets. Hand this Record ID to the doctor.

Patient Record ID

—

Next step: Give this Record ID to the attending doctor or physician. The doctor will enter this ID on their device to load the patient data and complete the clinical assessment (Sections 4, 5 and 6).

Doctor / Physician

Select a patient from the pending queue, or enter a Record ID manually.

Pending Patients 0

No pending patients yet

or enter Record ID manually

Patient Record ID

Same device as assistant? Continue from this session.

Prescriptions Queue 0

Completed patient records ready to print or download as PDF

No prescriptions yet · Completed records will appear here

Enter Your Mobile Number

Your mobile number is used as your patient ID. Enter the same number registered with the medical assistant.

Mobile Number

No records found for this mobile number. Please check the number and try again.

Loading patient data…

Doctor — Patient Record — loaded. Sections 1–3 are read-only. Please complete Sections 4, 5 and 6 then submit the final record.

Patient Summary (from Medical Assistant)

Doctor's Assessment

Suggested Diagnostic Tests

Recommended Medicines

Food Recommendation

Exercise Recommendation

Provisional Diagnosis

Follow-up Recommended

Recommended Medical Leave

Leave From (start date)

Leave Up To (end date)

Attending Professional

Doctor / Staff Name *

BMDC Reg. No. *

Designation / Role

Facility / Factory

Entry Date *

Additional Notes

Completes the record in Google Sheets · PDF prescription will be available

Record Complete & Saved

All sections saved to Google Sheets. The prescription has been added to the Print Queue — the medical assistant or front desk can open it there to print or download the PDF.