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ADMISSION HISTORY PHYSICAL EXAM & TREATMENT PLAN

Patient ID

***

IP No:

***

Doctor

***

Patient Name

*** , ***

Admission Date

***

Bed

***

PRESENT COMPLAINT

HISTORY

PHYSICAL EXAMINATION

GENERAL EXAMINATION

LOCAL EXAMINATION

ASSESMENT/DIAGNOSIS

ADMISSION ORDER/PATIENT CARE PLAN

Approximate Cost has been explained to the patient/Relative

Doctors Signature

Date