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Ticket No

Token No

Visit Date

Followup to(if Applicable)

Complaints

Remarks/Follow-up Investigation Details

Examination Findings

Diagnosis

Ailment System

Medicine Disbursement

Doctor Discussed?

Doctor Consulted?

Additional Recommendations(If Any)

Referral

Follow-up

Emergency? :

SBP:

DBP:

Heart Rate:

FBS:

RBS:

PPBS:

Temp:

SPOC2%:

Affected Body Parts

Health Advices

Doctor Recommended Tests

Additional Precautions

Follow-Up Remarks(If Any)

Test Result