School of Health Sciences

Medical Evaluation Performa

Name_________________________________ Age_____________ Gender______________

Date of Admission___________________ Mode of Admission___________________ S/O D/O__________________

Address____________________________________________________________ Blood group_________________

Height______________________ Weight___________________ BMI___________________________

Department_____________________________ Duty Doctor_______________________

Presenting Complaints:

1.

2.

3.

4.

5.

History of Present Illness:

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Past Medical History:

Yes No Yes No Yes No

DM   HBV/HCV   Psychiatric Disorder  

HTN   TB   IHD  

Asthma   Migraine   Epilepsy  

Surgical History:

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

Family History:

Yes No Yes No Yes No

DM   Carcinomas   DVT/PE  

HTN   TB   IHD  

Asthma   Epilepsy  

Gynecological & Obstetrical History___________________________________________________________________

__________________________________________________________________________________________________

Drug History______________________________________________________________________________________

__________________________________________________________________________________________________

Personal & Social History____________________________________________________________________________

__________________________________________________________________________________________________

History of Blood Transfusion_________________________________________________________________________

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General Physical Examination:

BP mmHg Jaundice
Temperature F Edema
Respiratory Rate /min Cyanosis
Pulse Rate /min Clubbing
GCS /15 Lymph Nodes
Pallor Weight (Kg)

Local Examination:

Differential Diagnosis:
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Systemic Review Notes:

Respiratory System

Gastrointestinal System

Musculoskeletal System

Cardiovascular System
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Central Nervous System

Special Senses

Provisional Diagnosis: ______________________________________________________________________________

Investigations Advised:

CBC X-RAY
LFTs Urine.R/E
RFts RBS
Hbs, Anti-HCV Serum Electrolytes
HIV Others

Impression and Request for Refferal(s) If any: