                                             DANDEKAR HOSPITAL

                                                    B Wing, Kasturi Plaza. Manpada Road, Dombivli (East)
                                       Ph .: 2862337 / 2862509 / 2862435 / 9819224069 / 7718021425 / 9619292669
                                                    OPD INITIAL ASSESSMENT FORM


                                                                                                                                                     15132
                           Vaishali Thakurdesai                                       Age 40 Gender F                           ......... UHID No.
  Patient's Name
                                  N.P. Dandekar Date: 16/8/23
  Doctor's Name : .




   Presenting Complaints :


                                                                   Uyenay




                                                                       incontinence


  H/O Allergies :

 Past History :


 Medical :                                                      adv.



 Surgical :




 Previous Investigation Reports :                                   1 Cap/Tab= NIFTRAN
                                                                                                                   (100)




 Family History :



                                                                                              ESOFOR/ or ESOGRESS                                    (4)
 Personal History : Addiction :                                                   T


 Physical Examination : 5 days (2)



General Condition : Good / Fair /Poor


                                                                                              PROFUR
Any Other Positive Findings :                             3) Cap



Systemic Examination :




                                                                                             MALTIFOR gold
Abdominal Examination :                                 (4)              Cap




                                                                                                                  Dr. Niteen P. Dandekar \

                                                                                                                           M.S ., M.Ch. (URO)

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