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BL.P. H.R. TEMP. R.R.

COMPLAIN: …………………………

Present H.:
………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………

Gyne.&Obst. H. : ………………………….

Past. H. :

EXAMINATION :

Investigation :

Provisional Diag. :
Treatment :

Consultation : ( of other physians)


Dear colleague : ………………………………..

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