Model Proforma Of Medical Report 470 - Legal Draft
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Model Proforma of Medical Report
Name :........................................ Dept. .......................................
Family History:
Illness in Family : T. B:........................ Diabetes : ................................
Hypertension .................................. Epilepsy : ...............................
Psychiatric illness :..............................
General ExaminationFamily History:
Illness in Family : T. B:........................ Diabetes : ................................
Hypertension .................................. Epilepsy : ...............................
Psychiatric illness :..............................
Digestive System
Height Skin Teeth Gums
Weight Nails Tonsils Nodes
Appetitive Flatulence Liver Worms
Bowels Pain Spleen Tongue
Nervous System
Palpitation Duspones Hear sounds B.P.
Pain Oedema Pulse
Intelligence Motor Systems Reflexes
Cranial Nerves Sensory System
Urogenital System
Cough Wheezing Screening of Chest Abnormal sounds
Sputum Breath sounds
Urine Hydrocele AIDS
Hemia V.D.
...............................................................................................................................................................
Remarks.................................................................................................................................................
Date:.............
Remarks.................................................................................................................................................
Date:.............
Signature of the Medical Practitioner