Digicon

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@csrf

@if (isset(session()->get('doctor')['vCentralCode']))

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(Kindly fill the relevant information or tick, as appropriate.)

@if (isset(session()->get('doctor')['vCentralCode']))

Name of Doctor*

@else

Name of Doctor *

@endif

Age (in Years) *

Weight (in kg) *

Date of Visit *

<28 weeks 28-32 weeks 32-37 weeks

Past Obstetric History *
Previous Pregnancy	Yes No
Complications with Previous Pregnancy	Yes No Not Applicable
If yes, details of complications with previous pregnancy Mother * Baby *
Gravidity	0 1 2 3 4 ≥5
Parity	0 1 2 3 4 ≥5
Number of living children	0 1 2 ≥3
Number of abortions	0 1 2 3 4 ≥5
Number of failed ARTs	0 1 2 ≥3

Reasons for choosing SUSTEN Capsules * (Kindly tick the potential reasons)
Tolerability	Reliability
Patient compliance	Effectiveness