                                 ······ ······                                                                                                Hosp. No. 1
                                                                                                                                                                                   IP No.
                                                                                                                                               Date: 6/3/201
                 alshifa                                                                EMERGENCY                                                                                           Time : /
                                                                                                                                              Name of Patient : Shahid-Kann
                                                                       INITIAL ASSESMENT FORM
                                                                                                                                              Age +          Gender+-
                 MULTI SPECIALITY HOSPITAL                                                                                                                                        Ward/Bed No.+
                Run by Human Welfare Trust                                       1380379                                                     Address !
                D-305, Abul Fazal Enclave,
                Jamia Nagar, New Delhi - 110025
               Tel. : +91 9818 844 498.
               9015 163 363. 011-4151 3520                                                                                                                        Contact No.1
               E-mail: info@alshifahospital.net                                        S. No .: 25185
                                                                                                                                             Referred by :
              Vitals
                                                                   Time of Arrival : 2.55 Am/PM                                                                          2.11 AM/PM
                 Height (cm) :                                                                                                        Time of Assessment
                 Weight (kg) :                                    Triage !        [ Red [ Green D Yellow
                                                                                                                                   D Black | Brought Dead: DYes ONo
                 P.R. :                                          Chief Complaints & H/O Present Illness
                 B.P. :    140/70                                                                                                Nausea               lion
               R.R. !
               Temp .: 37                                        Past History : D DM CHTN
                                                                                                                   DIHD/VHD/AF OMI D COPD/Bronchial Asthma
                                                                                      OCKD O CLD                 O Thyroid | Stroke (CVA) : DIschemic [Bleed
          Others :
                              162                                                       Drug History :
              R.B.S .:
              SpO2:                                                                     History of Allergies
                             tout

        Investigation Advised :                                                      Any Other :
                                                               General Physical Examination
                                                                                                                Pt cancun, crialed P/

                                                                                                                                                                                                       -

                                                              Systemic Examination

                                                                                                        P/A - SATINTIND dub)
                                                                                                                                                                                                            P
                                                                                                                                 BS-1
                                                             Recondition Medication




    Nutritional
    Screening/ Assessment :                                 Provisional Diagnosis :
                                                            Treatment :
                                                                                                                   - 24 portand 4og livs11




                                                                                                B-A S.R. nict

                                                                                                                                                                 1spac
                                                                                                                           Montop-11
                                                                                                                                                                                                           1o
Preventive Advice :                                                                                                                                                          -
                                                                                                                               quant it


Follow up :                                          Advice Admission / Refer/Discharge/ LAMA : , R/cm
                                                      Treatment Advice on Discharge / Refer :                                                                         Mid 095 cl

                                                                                                    1

                                                    DOD :                         Time : __:_ Transfer to :
                                                                                                                                                                or Refer to :
in Score : VAS                                      Attending Doctor's Name :
                                                   (In Block Letters)                                                                                         Signature :_
                                                  Inform to Consultant :                    DYes ONo
                                                                                                                                                                                 6/3

                                                 Consultant's Name : Jan.
                                                 (In Block Letters)
                                                                                                                                                             Signature
                                                 Patient's Attendant Name : Janineer Almeno
                                                                                                                                                             Signature : Cture




                                                                                                                                             AMSH/Doctor/Emergency Service/Rev. 2/2022

{'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': 'Jan', 'doctor_qualifications': 'NA', 'doctor_registration_number': 'NA'}, 'patient_details': {'patient_name': 'Shahid-Kann'}, 'prescription_details': {'date_of_doctor_consultation': '6/3/201'}, 'procedure': {'chief_complaints_diagnosis': 'Nausea, Lion'}, 'medicine_details': [{'medicine_name': 'PAN 40', 'medicine_dosage': '1-0-1', 'medicine_frequency': 'Morning, Night', 'course_duration': 'NA'}], 'lab_test_details': {'lab_test_names': 'NA', 'procedure_request': 'NA'}}