| Age: |
Sex: |
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| General
Practitioner: |
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| Specialist
Name: |
Speciality: |
| 1. |
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| 2. |
|
| 3. |
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| 4. |
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| 5. |
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| |
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| Blood
Pressure: |
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| |
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| Date |
Systolic |
Diastolic |
|
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| Investigations: |
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Urine:
1. Routine:
2. Culture:
3. Screening: |
|
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| |
|
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| Motion: |
HB
%: |
TC: |
| DC: |
ESR: |
Blood
Group: |
| Blood
Sugar: |
Blood
Cholesterol: |
|
| |
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| Enzymes: |
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| |
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| CSF
Analysis: |
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| |
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| X-Rays: |
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| |
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| C.T.
Scan: |
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| |
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| M.R.I.
Scan: |
|
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| |
|
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| Spect: |
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| |
|
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| E.C.G: |
|
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| |
|
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| Biopsy: |
|
|
|
|
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| |
|
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| Others: |
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| |
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| |
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| Hospital
Admission: |
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| |
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