                                                                                                                                Hosp. No. :                      IP No.
                                                                                                                                 Date : 16/09/2023                        Time :           -
                                                                                                                                 Name of Patient : Onehdiffasen Khan
                                                                          EMERGENCY
               alshifa®                                                                                                          Age : 23 Gender : [ Ward/Bed No .:
                                                      INITIAL ASSESMENT FORM

                                                                                                                                  Address :
                MULTI SPECIALITY HOSPITAL                                          410743
               Run by Human Welfare Trust
               D-305. Abul Fazal Enclave,
                                                                                       32117                                                         Contact No. :
               Jamia Nagar, New Delhi - 110025
               Tel. : +91 9818 844 498.
               9015 163 363. 011-4151 3520                                S. No.                                                  Referred by :
               E-mail: info@alshifahospital.net
                                                                                   10:50 Am 1PM                                                           10:50 AMPM
                                                     Time of Arrival :                                                      Time of Assessment :
               Vitals
                  Height (cm) :                     Triage :      Red OGreen O Yellow                            Black | Brought Dead : Yes SSo
                 Weight (kg) :                      Chief Complaints & H/O Present Illness : Cto Epigastric Pain x pince
                                  18 0p
                 P.R. :
                 B.P. :       110/20mH                                                                                                                                       afternoon

                R.R. :                                                                       HIN          IHD/VHD/AF DMI O COPD/Bronchial Asthma
                                                    Past History : [] DM
                Temp .:          Mads
                                                                           D CKD         D CLD            Thyroid || Stroke (CV A); E]Ischemic [] Bleed
                                                                                                                                    Ho, fever (4)
         Others :                                                              Drug History :
               R.B.S.                                                                                                No
                             Jaof anQ.A                                        History of Allergies :
            SpO2:
                                                                               Any Other
       Investigation Advised :                      General Physical Examination                         0)6: Conscious, Oriented


   - VGWA

                                                   Systemic Examination

   - LIFT


                                                    Recondition Medication
       - CBC.                                                                                                   RISPEBE




       Nutritional                                 Provisional Diagnosis        Sill Digecaine 30ml statt
       Screening/ Assessment :                      Treatment :


-Aroid Spicy &oily
                                                                                                                              then 15ml Box 3dia

                     food.



                                                                           Cap. Jan-DSR 100
   Sofi giel




    Preventive Advice :                                                  - T. Dolo 650 mg
                                                                                                                                                                                       n

                                                   Advice Admission / Refer/ Discharge / LAMA :
    Follow u                                       Treatment Advice on Discharge / Refer ;
                                                                                                   Doctin (DS 1B) × 3 day
 B / w RM


                                                                                    Time :                 Transfer to :                                               or Refer to :
medicine                                          DOD :                                            Orkameez

                                                                                                                                                                     Signature :
   Pain Score : VAS                               Attending Doctor's Name
                                                  (In Block Letters)
                                                  Inform to Consultant :                            Yes ONo



                                                                                                                                                                      Signature :
                                                  Consultant's Name :
                                                  (In Block Letters)
                                          10                                                                                                                          Signature:
                          Seve                    Patient's Attendant Name :

{'clinic_pharmacy_details': {'clinic_pharmacy_name': 'alshifa®', 'clinic_pharmacy_address': 'D-305. Abul Fazal Enclave, Jamia Nagar, New Delhi - 110025', 'clinic_pharmacy_city': 'New Delhi', 'clinic_pharmacy_pincode': '110025'}, 'doctor_details': {'doctor_name': 'NA', 'doctor_qualifications': 'NA', 'doctor_registration_number': 'NA'}, 'patient_details': {'patient_name': 'Onehdiffasen Khan'}, 'prescription_details': {'date_of_doctor_consultation': '16/09/2023'}, 'procedure': {'chief_complaints_diagnosis': 'Cto Epigastric Pain'}, 'medicine_details': [{'medicine_name': 'Sofi giel', 'medicine_dosage': 'NA', 'medicine_frequency': 'NA', 'course_duration': 'NA'}, {'medicine_name': 'Cap. Jan-DSR 100', 'medicine_dosage': 'NA', 'medicine_frequency': 'NA', 'course_duration': 'NA'}, {'medicine_name': 'T. Dolo 650 mg', 'medicine_dosage': 'NA', 'medicine_frequency': 'NA', 'course_duration': 'NA'}], 'lab_test_details': {'lab_test_names': 'NA', 'procedure_request': 'NA'}}