Name of Hospital……………………..……………..

Department of………………………………………..

Date:…………. Clinic No:………. Examined by:…………

Consultant:…………….

Name of patient:………………………. Age:…….. Sex:…

Occupation:………………… Marital Status:………….

Address:…………………………………………………. Phone no:………………

Presenting complaints with duration:

History of Present Illness:

Past illness:
………………………………………………………………………………………………………
……………………………………………………………………………………………..

Personal history:

Exercise:

Sample diet:

Breakfast

Snack

Lunch

Tea

Dinner

Calories

Smoking : Tobacco chewing

Alcohol:
Other symptoms (if any):

Physical Examination:

Pulse:………… Blood pressure…………. Height………….

Weight………………. BMI:…………

General Apperance:

Skin Pigmentation Short 4th metacarpal

Hypertelorism Simian crease

Depressed nasal bridge Carrying angle

Clinodactyly

Hair Distribution:

Acanthosis-nigricans

Oral Cavity

Breast

Expressive galactorrhea

INVESTIGATION RECORD

HEAMATOLOGY:

Hb:

Blood picture

Total blood count(WBC)

Differential count

Platelet count

URINE:

pH : WBC:

Alb: Counts:

Sugar: Acetone:
 RBC:

SERELOGY:

RA Factor Complement

LE Cell

ANA

VDRL

BIOCHEMISTRY

LIPID PROFILE:

Cholestrol

Triglyceride

HDL

LDL

Lp(a)

LFT:

Total bilirubin

Total Protein/albumin/globulin

SGOT

SGPT

Alkaline phosphatase

FOLLOW UP RECORD

Date: Wt: Ht: DATE: WT: Ht:

Pulse: Temp: B.P. P: T: B.P.
Date: Wt: Ht: Date: Wt: Ht:
Pulse: Temp: B.P. Pulse: Temp: B.P
Date: Wt: Ht: Date: Wt: Ht:
Pulse: Temp: B.P. Pulse: Temp: B.P.
Date: Wt: Ht: Date: Wt: Ht:
Pulse: Temp: B.P. Pulse: Temp: B.P.
Date: Wt: Ht: Date: Wt: Ht:
Pulse: Temp: B.P. Pulse: Temp: B.P.
Date: Wt: Ht: Date: Wt: Ht:
Pulse: Temp: B.P. Pulse: Temp: B.P.
Date: Wt: Ht: Date: Wt: Ht:
Pulse: Temp: B.P. Pulse: Temp: B.P.

HORMONE ASSAYS

T3 S. insulin

T4 Blood glucose

Free T4 S.Progesterone

Thyroid antibody 17(OH)progesterone

FSH Serum cortisol:

LH 8 am:

Prolactin 4 pm:

S. Testosterone Random

S. Estradiol Post Synacthen

DHEAS Basal