  SURYA

  Mother & Child Care
                                                                                                                                                       NABH


                                                                                                                                                 H-2021-0797
                             OUT-PATIENT ASSESSMENT FORM (Paediatric/Neonate)


      Name : Niavi Jain                                            Age : 1.61 Sex : F PRN : 62473 Date : 27/2/23


     Allergy (if Any) :                                                                                    Height : 77cm Weight : 8.2/4


      Chief Complaint:                                             Examination:
                                                                   Pulse -                                        Temperature-

                                                                                                                                                  47cm
                                                                   RR-                                            Head Circumference
                                                                   Nutritional screening -
                                                                          · Well nourished
                                                                          · Underweight                                          Palet
                                                                           · Overweight
                                                                   Reference to Dietician [ ] Yes [ ] No


    Provisional Diagnosis:


                                                                                       HURTS LITTLE MORE
                                                                   NO HURTHURTS LITTLE BIT                       HURTS MIGUELOF
                                                                                                     HURTS EVEN MORE
                                                                Pain Score:


   Treatment:
                                                                                                                         11/8000/4.64



   Calshine P                                                                                                             (cridehydrationi)

                                                       10      contenue

  Calcimaxp




 Syp Calpol - 250mg 2ml 6 hourly



                                                 for temp = 100F




 Syp Raricap-L 5ml daily once × 1 month


                                                                                     Advice, if any:
   Investigation:
                                                                    Akar
                                                                                Next Follow up:
                                                      Dr. Amita Kaul®
                                                M.B.B.S .; D.N.B.(PEDIATRICS)
                                                                                                                Time :                        Sign :
Name of Consultant with Reg. No .: Reg.No. 2002/04/197.

                                                                              T : 020 - 67915400 / 67915466 /55          E : hrpune@suryahospitals.com
SMCSSH/MED/F/03           Surya Mother and Child Care Pvt. Ltd.
                                                                                E: 020 - 67915400                        Website : www.suryahospitals.com
                          Sr. No. - 8. Devi Yash. Noar Wakad Octroi Naka,
                                                                                Paediatricians available 24x7
                          Hinjewadi fly Bridge, Wakad, Pune - 411057                                                                                    CONFIDENTIAL
                                                                                18002665400

{'clinic_pharmacy_details': {'clinic_pharmacy_name': 'Surya Mother and Child Care Pvt. Ltd.', 'clinic_pharmacy_address': 'Sr. No. - 8. Devi Yash. Noar Wakad Octroi Naka, Hinjewadi fly Bridge, Wakad, Pune - 411057', 'clinic_pharmacy_city': 'Pune', 'clinic_pharmacy_pincode': '411057'}, 'doctor_details': {'doctor_name': 'Dr. Amita Kaul', 'doctor_qualifications': 'M.B.B.S .; D.N.B.(PEDIATRICS)', 'doctor_registration_number': 'Reg.No. 2002/04/197'}, 'patient_details': {'patient_name': 'Niavi Jain'}, 'prescription_details': {'date_of_doctor_consultation': '27/2/23'}, 'procedure': {'chief_complaints_diagnosis': 'NO HURT HURTS LITTLE BIT, HURTS LITTLE MORE, HURTS EVEN MORE, HURTS MIGUELOF'}, 'medicine_details': [{'medicine_name': 'Calshine P', 'medicine_dosage': '10 contenue', 'medicine_frequency': '1-0-1', 'course_duration': '4.64'}, {'medicine_name': 'Calcimaxp', 'medicine_dosage': 'NA', 'medicine_frequency': '1-0-1', 'course_duration': 'NA'}, {'medicine_name': 'Syp Calpol', 'medicine_dosage': '250mg 2ml', 'medicine_frequency': '6 hourly', 'course_duration': 'for temp = 100F'}, {'medicine_name': 'Syp Raricap-L', 'medicine_dosage': '5ml', 'medicine_frequency': 'daily once', 'course_duration': '1 month'}], 'lab_test_details': {'lab_test_names': 'Akar', 'procedure_request': 'NA'}}