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CASE PRESENTATION
1. Patients Biodata:
Name: ____________________________________________________________
OPD No: ____________________________________________________________
IPD No: ____________________________________________________________
Age/Sex: ____________________________________________________________
Address: ____________________________________________________________
Marital Status: ______________________________________________________
Educational Status: ________________________________________________
Occupation: ______________________________________________________
Family Income: ______________________________________________________
Source of Health care: ________________________________________________
Date of admission: ________________________________________________
Diagnosis: ______________________________________________________
Name of Surgery: ________________________________________________
Date of surgery (If done): __________________________________________
Date of discharge:. ________________________________________________
2.Present complaints: ___________________________________________________________________
_____________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
3.History of Present illness:
Onset: __________________________________________________________________________
Symptoms:_________________________________________________________________________
__________________________________________________________________________________
Duration:__________________________________________________________________________
Precipitating factors: ______________________________________________________________
Any other : ___________________________________________________________________
