‫الرقم‬

Health Care No 15910 ‫الصحي‬

MANSOUR NASSER
Name ‫االسم‬
AL SAIF
Age 47 ‫العمر‬ Sex M ‫الجنس‬
Eradah Complex of Mental Health Nationality SAUDI ‫الجنسية‬
Medical Referral Center
Consultant In- ‫االستشاري‬
Department of Eligibility for Treatment DR OMIMA ABED AL MONEEM
charge ‫المسئول‬
and Medical Coordination

.Dept INTERNAL ‫القسم‬ Unit ‫الوحدة‬

REFERRAL FORM ‫نـمــوذج تـحـــــويـــــــل‬

TO DR UROLOGY CLINIC DEPT UROLOGY CLINIC
DESIGNATION HOSPITAL / PHC
FROM DR MAZEN HAJ AHMAD DEPT INTERNAL
DESIGNATION AL-Ekhaa Center HOSPITAL / PHC ERADAH COMPLEX IN Riyadh
Clinical history: K/C chronic schizophrenia put on: risperidone 2mg bid ,sodium valproate 1000mg am &500 mg pm , HTN
ON :Atenolol 25 mg AM

PHYSICAL EXAMINATION: K/C chronic schizophrenia put on: risperidone 2mg bid , sodium valproate 1000mg am &500
mg pm , HTN ON :Atenolol 25 mg AM

The patient complains of pain and bleeding from the anus frequently, treatment by Haemoproct Suppositories and
ointment

We refer him to you for evaluation and treatment

With full thanks …

DIAGNOSIS
Provisional diagnosis : pain and bleeding from the anus frequently
PATIENT'S CONDITION : Stable  Critical  Conscious  Unconscious
REASON FOR REFERRAL :  Consultation & Treatment  Admission
… Further Investigation Other :
TRANSPORTATION :  Ambulance  Helicopter Air Other:…patient herself…….
ESCORT : None Doctor Nurse Relative Other:…………..
DOCUMENTS SENT : Med.Report Lab.Result X-ray  Other:…………..
MAZEN HAJ AHMAD
Dr.'s Name
Date : 30/05/2022
Mobile # 0595603653

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