|
O.P.D No |
: [OPPTNO]
|
Name |
: [PTNAME]
|
[IMGPHOTO]
|
|
I.P.D No |
: [IPPTNO] |
Father/Husband's Name |
: [PTFNAME] |
|
Date and Time of Arrival |
: [DTEXAM] |
Address |
: [ADDRESS] |
|
Name of Police Station |
: [STATION] |
|
|
|
Police Report No
|
:
[PRNO]
|
Religion |
:
[RELIGION]
|
Age: |
[AGE]
|
|
Sex: |
[SEX] |
|
Date Police Informed |
: [DATEINFORM] |
Occupation |
: [OCCUPATION] |
|
Time Police Informed |
: [TIMEINFORM] |
Marks of identification[1] |
: [MARK1] |
|
|
|
Marks of identification[2] |
: [MARK2] |
|
Name and Address of Accompanying Person |
: [WHOMBR] |
|
Place of Accident |
: [PLACEOFACCIDENT] |
| History |
: [CAUSE] |
| On Examination |
: [INJURIES] |
| Investigations |
: [INVGST] |
| Conditions at Discharge |
: [CONDIS] |
| Final Diagnosis |
: [DIAGNOSIS] |
| Nature of Injuries |
: [OPNINJ] |
| Kind of Weapon used or poison suspected in case of poisioning |
: [WEAPON] |
| |
|
| If admitted:Date of admission: |
: [ADMDATE] |
Date of discharge |
: [DISDATE] |
| Remarks |
: [REMARKS] |
| Payment Type: |
: [PTYPE] |
[PAYMENTLABEL] |
[PAYMENTNO] |
| |
|
| |
|
|
|
|
|
[MEDICALOFFICER]
[INSTITUTION] |
|
| |
|
