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Patient Profile Form

The document is a patient profile form used by the Department of Pharmacy Practice at Narayan Medical College & Hospital. It includes sections for patient information, medical history, physical examination, provisional diagnosis, biochemical investigations, urine analysis, final diagnosis, drug treatment chart, and discharge medications. This form is designed to collect comprehensive data for patient management and follow-up care.

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avi837001
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8 views2 pages

Patient Profile Form

The document is a patient profile form used by the Department of Pharmacy Practice at Narayan Medical College & Hospital. It includes sections for patient information, medical history, physical examination, provisional diagnosis, biochemical investigations, urine analysis, final diagnosis, drug treatment chart, and discharge medications. This form is designed to collect comprehensive data for patient management and follow-up care.

Uploaded by

avi837001
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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PATIENT PROFILE FORM

DEPARTMENT OF PHARMACY PRACTICE – NIOP


NARAYAN MEDICAL COLLEGE & HOSPITAL
JAMUHAR, ROHTAS, BIHAR

PATIENT NAME: HOSP. NO.: DATE OF ADMISSION:

AGE: WEIGHT: SEX: M/F DATE OF DISCHARGE:

COMPLAINTS ON ADMISSION:

MEDICAL HISTORY:
MEDICATION HISTORY:

SOCIAL HISTORY:
FAMILY HISTORY:`
PREVIOUS ALLERGIES:

PHYSICAL EXAMINATION:
GENERAL -
VITAL SIGNS -
HEENT -
CVS -
RS -
GIT -
GU -
EXT -
CNS -

PROVISIONAL DIAGNOSIS:

ROUTINE BIOCHEMICAL INVESTIGATIONS HAEMATOLOGY:


Urea: RBS: Alb: RBC : Retics:
S.Cr : Tch : Glob: WBC: Hb:
N: PCV:
Na: TGs : AST: L: MCV:
K: T Bili: ALT: M: MCH:
ALP: E: MCHC:
FBS: D Bili:
B: ESR:
PPBS: T. Prot:

URINE ANALYSIS OTHERS


pH: WBC:
Protein: RBC:
Sugars: EP. Cells:
Blood: Casts:
Crystals:
FINAL DIAGNOSIS:
DRUG TREATMENT CHART: PROGRESS CHART:
DRUG WITH DOSE & ROUTE DAY INVESTIGATIONS
1 2 3 4 5 6 7 8 9 10
GENERIC NAME BRAND NAME

DISCHARGE MEDICATIONS:
FOLLOW UP/REVIEW:

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