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Medical record No

In time

Clearance time

Case Type

Referred By

Complaints

Diagnosis

,

Examination Findings

Disease Type

Body System

,

Remarks/Follow-up Investigation Details

Medicine Disbursement

Doctor Discussed?

Doctor Consulted?

Additional Recommendations(If Any)

Referral

Follow-up date

Emergency? :

Heart Rate:

SBP:

DBP:

FBS:

RBS:

PPBS:

Temp:

SPOC2%:

Affected Body Parts

Health Advices

Doctor Recommended Tests

Additional Precautions

Follow-Up Remarks(If Any)

Test Result