                                                                                                                                               AASTHA
                                                      KHAPEKAR
                                                      HOSPITALS                                                                               CHILDREN'S HOSPITAL
                                                      PRIVATE LIMITED                                              A Unit of Khapekar Hospitals Private Limit

                                 Piot No 35. Dayakrishna Sankut Central Bazar Road, Ramdaspeth, Nagpur - 440 010
                                                            OPD Patient Counselling Form

          UNID: OPD30926,
          Name of Patient :- B/O PRIYANKA ANAND PAHADE,                                                      Age - 6 Day.
         Sex :- MALE, Mobile: 8208806788
        Weight : 1.700 kg, Height : 42cm No. of Child : 1" Child 200 Child 3" Child

        Contact No (Whatsapp] Father/Mother                                                                   Patients OutSide/Local
        Address : AT. DIGHORL, NAGPUR
        Occupation of Parents : Govt. Servant ..                                       . Pvt. Job                 Business

       Purpose of Visit : General Check-up, Vaccination, Growth & Development, Diet Counselling.
       Surgical, Illness
       New Born Patient Status :
       Birth Weight :1.8.Kg. Height :42 cm, HC: 31.cm
       Gestation Age: Pre Term / Full Term NICU Adm : Yes/No Pregrency Outcome : Good/Poor
     Place of Delivery : Govt. /Put. /Other                                                         Type of Delivery: Normal /LSCS

    Feeding History : Breast Feeding : Yes/No Top Feeding :Formula: Yes/No Cow Milk : Yes/No
     Health Status:
     Normal,            Stunting, Under weight, Overweight, Obesity , Development Status:
    Immunization : Govt./Pvt .                                                                                  Complete/Incomplete
   Vaccination Due : Typhoid /Chicken Pox/ Hepatities A / Influenza /Cervical Cancer
   Complaint :

  Diagnosis :

  Rx                                                                                                  VI1 73 0.5

  Medicine

 Diet Counceling                                                           1               5 Cal cimos 250

 Immunazation : Yes/No

 Pre Pregnancy counselling

First 1000 days/ Aastha Channel


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