                                                                                                                                                       NABH
     SURYA

     Mother & Child Care                                                                                                                            H-2021-0797



                                 OUT-PATIENT ASSESSMENT FORM (Paediatric/Neonate)


                                                                         Age : 1.8 y Sex : F PRN : 62473 Date : 7/03/23
         Name : Mirui Jain
                                                                                                                Height : 77cm Weight: 8.2/19

         Allergy (if Any) :

                                                                        Examination:
         Chief Complaint:                                                                                              Temperature-
                                                                        Pulse .

                                                                                                                       Head Circumference-
          Cold × 1 day                                                   RR-
S                                                                       Nutritional screening -
                                                                               . Well nourished
F                                                                              · Underweight
                                                                               · Overweight
                                                                        Reference to Dietician [ ] Yes [ ] No


        Provisional Diagnosis:

         ARI                                                                                                        MORTS EVEN   HURTS WHOLE LOT
                                                                                                                               MORE
                                                                                      HURTO           HUNTS LITTLE MORE
        Recement episode
                                                                        Pain Score:


        Treatment:


         Nasodear nasal spray 6 hourly




      Syp cebine 1ml 2 times a day x5 days.




      Huf puf kit




       Budecort 200 mcg 1puff 2 times a day



                                                                                                                × 1 month.
       feen chanti



      Investigation:                                                                       Advice, If any:


                                                                                           Next Follow up:

                                                       Dr. Amita Kaul
    Name of Consultant with Reg. No .: M.B.B.S .; D.N.B.(PEDIATRICS)
                                                                                                                     Time :                       Sign :
                                                    . . Reg.No. 2002/01/193 7 400 / 67915466/55
    SMCSSH/MED/F/03           Surya Mother and Child Care Pvt. Ltd.
                              Sr. No. - 8, Devi Yash, Near Wakad Octroi Naka,                                                  E : hrpune@suryahospitals.com
                                                                                    E: 020 - 67915400
                              Hinjewadi fly Bridge, Wakad. Pune - 411057                                                       Website : www.suryahospitals.com
                                                                                    Paediatricians available 24x7
                                                                                      18002665400
                                                                                                                                                            CONFIDENTIAL

{'clinic_pharmacy_details': {'clinic_pharmacy_name': 'Surya Mother and Child Care Pvt. Ltd.', 'clinic_pharmacy_address': 'Sr. No. - 8, Devi Yash, Near 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': 'SMCSSH/MED/F/03'}, 'patient_details': {'patient_name': 'Mirui Jain'}, 'prescription_details': {'date_of_doctor_consultation': '7/03/23'}, 'procedure': {'chief_complaints_diagnosis': 'Cold for 1 day'}, 'medicine_details': [{'medicine_name': 'Nasodear nasal spray', 'medicine_dosage': '6 hourly', 'medicine_frequency': '2', 'course_duration': '5 days'}, {'medicine_name': 'Syp Cebine', 'medicine_dosage': '1ml', 'medicine_frequency': '2 times a day', 'course_duration': '5 days'}, {'medicine_name': 'Huf puf kit', 'medicine_dosage': 'Not specified', 'medicine_frequency': 'Not specified', 'course_duration': 'Not specified'}, {'medicine_name': 'Budecort 200 mcg', 'medicine_dosage': '1 puff', 'medicine_frequency': '2 times a day', 'course_duration': 'Not specified'}, {'medicine_name': 'feen chanti', 'medicine_dosage': 'Not specified', 'medicine_frequency': 'Not specified', 'course_duration': '1 month'}], 'lab_test_details': {'lab_test_names': 'NA', 'procedure_request': 'NA'}}