Model Proforma of Medical Report

Name :…………………………………. Dept. …………………………………

Family History: 
Illness in Family : T. B:…………………... Diabetes : …………………………..
Hypertension ……………………………. Epilepsy : ………………………….
Psychiatric illness :…………………………

General Examination	Digestive System	
Height Skin Teeth Gums	Weight Nails Tonsils Nodes	Appetitive Flatulence Liver Worms	Bowels Pain Spleen Tongue	
Cardio - Vascular system	Nervous System	
Palpitation Duspones Hear sounds B.P.	Pain   Oedema  Pulse	Intelligence Motor Systems Reflexes	Cranial Nerves Sensory System  	
Respiratory System	Urogenital System	
Cough Wheezing Screening of Chest Abnormal sounds	Sputum Breath sounds  	Urine      Hydrocele AIDS 	Hemia  V.D. 	

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Remarks.................................................................................................................................................

Date:…………. 
Signature of the Medical Practitioner