                                                                     GYNAECOLOGY ASSESSMENT FORM
         N.
         RI         Consultant:                  De Thejaswini ]                                                                                  30.4.2023
         TI
                                                                                                                                      Date:

                    Patient Name:                     Auguna Base
         TI                                                                                                         Age / Gender:                             UHID:

                    Obstetric History:
                                                                        P           A            L                        Menstrual H/O: LMP



                                Syr Dexorange                                                                   0
      RI                                                                                                                                                              0


                                                                                                            1 Teu radix

                            7               Raclager. sotchets


   F
     c            Past History: Medical -
                                                                                                                                                              Special Assessment

                                         Surgical -                                                                                                           Functional assessment :
   IN
                                                                                                                     1-                  0                    Fall Risk Assessment :
  TI
                                                         I Dicales                                                                                            Phychosocial assessment
 Ic               Family History:                                                                                                                             Pain assessment : (Score 1-10)
  re
 fir
                                                                                                                                                              Investigations
Ple              Birth Defect History:
Me




                Chief C/O




               Clinical Findings




              Treatment / Follow-up Plan




                                                                                                                    motherhood



                                                           514/1-2-3, kaikondara village, opp more mega mall, sarjapur road, bengaluru 560 103 india
                                                                                                                                                         tel +91 (80) 080-42666000
                   NABH                                                                                                                      CIN No - U85110TN2008PTC067734

                                                                                                                                                     www.motherhoodindia.com

                                                                                                                                                                                               F -O

{'clinic_pharmacy_details': {'clinic_pharmacy_name': 'Motherhood', 'clinic_pharmacy_address': '514/1-2-3, kaikondara village, opp more mega mall, sarjapur road, bengaluru 560 103 india', 'clinic_pharmacy_city': 'Bengaluru', 'clinic_pharmacy_pincode': '560 103'}, 'doctor_details': {'doctor_name': 'Dr. Thejaswini De', 'doctor_qualifications': 'Consultant', 'doctor_registration_number': 'NA'}, 'patient_details': {'patient_name': 'Auguna Base'}, 'prescription_details': {'date_of_doctor_consultation': '30.4.2023'}, 'procedure': {'chief_complaints_diagnosis': 'Gynecology Assessment Form'}, 'medicine_details': [{'medicine_name': 'Syr Dexorange', 'medicine_dosage': '1 sachet', 'medicine_frequency': '1 time per day', 'course_duration': 'NA'}, {'medicine_name': 'Raclager', 'medicine_dosage': '1 tablet', 'medicine_frequency': '1 time per day', 'course_duration': 'NA'}], 'lab_test_details': {'lab_test_names': 'NA', 'procedure_request': 'NA'}}