SURYA



Mother & Child Care                                                                                                                                   NABH

                               OUT-PATIENT ASSESSMENT FORM (Paediatric/Neonate)
                                                                                                                                                   H-2001-0797

                             Nishi
      Name :_                                                                                                                                      27/2/23
                                                                       Age : Sy Sex : F                 PRN :                           Date:
      Allergy (If Any) :                                                                                                   115                          15.6
                                                                                                              Height :                    Weight :

      Chief Complaint:
                                                                      Examination:
                                                                      Pulse .                                       Temperature-

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

      Provisional Diagnosis:


          AGE
                                                                      NO HIANT                   HIRTS LITTLE MORE
                                                                  Pain Score:

      Treatment:



        Syp Domstal (1mg/ml)




                                         2ml 3 times a day x 3 days




      Ecogram GG 1 sachet / day x 5 days.




    Syp Carmicide Ped 3ml 3 times a day


                                                                                                                             × 5 days




   Investigation:                                                                     Advice, If any:


                                                         Dr. Amita KaNext Follow up:
                                                    M.B.B.S .; D.N.B.(PEDIATRICS)
                                                          Reg.No. 2002/01/197                                   Time :.                     Sign
Name of Consultant with Reg. No .:

SMCSSH/MED/F/03            Surya Mother and Child Care PVt. Ltd.                T : 020 - 67915400 / 67915466/55          E : write@suryahospitals.com
                           Sr. No. - 8. Devi Yash, Near Wakad Octroi Naka,       E: 020 -67915400                         Website : www.suryahospitals.com
                           Hinjewadi fly Bridge, Wknd, Pune - 411057            Paediatricians available 24x7
                                                                                 18002665400                                                          CONFIDENTIAL

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