Health Sector-———-—
REFERRAL & CONSULTA
Health Center
Date TS
Na, nt
Age cee tone
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jON FOR
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Spe asia Bs
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Immediate [] tas
Urgent [2m
elective [_] ease
: cf
mers
Other [___] 55" Private car[_] +++ t= Ambulance [_Joe=" + v2)
tS Any
Tame of referra EISE
PATIENT CONDITION Of REFERRAL;
PRD Ys aie phat ate
ws
Clinical examination
Complaint & duration Meike aS!
Temp Bp Resp.rate Pulse Wieght Height BMI
: sv Eps! yaorall
Investigation (Included)
‘Summary Of interventions
Provisional Diagnosis ...
Treatment Given ~~
(Time of last dose)
Reason of referral
Follow Up [Jam
Annual epeckup [Jas na
wg)
Danes dmareperece [J ySnasneaoe
Genera ehcp [“] tons
Upon Pavents Request [“] sets ey
BY
Stamp & Sign of treating Physician
Stamp & Sign of technical director
J AagBsSg Tat tan iS
| dndsg ASN post SS