†iwR÷vW© bs wW G-1

evsjv‡`k †M‡RU
AwZwi³ msL¨v
KZ…©c¶ KZ…©K cÖKvwkZ

g½jevi, A‡±vei 29, 2019

: !"#/"! % & " ' () *

!. . . !,. ,. -. #-, " / 0 , 2 , 3 , 45
6 7 2, 8 9 : ; <= > 4 <? @
<= > 4 A 3 @ @ , B C % D < E 4
4 FE %? @ , GD H I 3 J
< @ , 3K H B C L @ M/
N “ /0 , 2 , 3 , 45 6 7 2, 8 9 :
; <= > 4 <? @ PB Q " '( S )”
%V @ ।

X < =

Y B ( Z©= )।

( 24285 )
g~j¨ : UvKv 20.00
24286 evsjv‡`k †M‡RU, AwZwi³, A‡±vei 29, 2019

/0 , 2 , 3 , 45 6 7 2, 8 9 :
; <= > 4 <? @ PB

[ :

S %S J ‘@ Z= ’ : ^
_`D H % @ 4 <? @ ? । 7 a " '- , " - ,
" - " H " "- , %? b S %S J ^
Support Services for Vulnerable Group (SSVG) c d <H /0 ,
2 , 3 4 <= > 4 : - , ( e @ )f
@ <? @ @ b। g '! h @ : !'" h
Y : Z= B @ i। j 45 6 7 2, ; H
8 9 <= > 4 @ k4 Z= " ,- ! %? b a b
। /0 , 2 , 3 , 45 6 7 2H 8 9 <= >
4 <? @ PB PB @ B @ i। 7l k
: 0 J B % / 0 (<7:< ) H / 0 4 7h ; ,
/0 4 m = n o p i। 4 /0 4 m
" M। : 4 ^q q ,r @ , s , t H Q / 0 <= > m 7
4 । @ 4 ^ , 3 t-r / 0 <= > । % Z u B C
A D < % B <= > 4 ^ b ## Z i।
"4 h 4 2 4 <= > । Z ^ m7 4 । : 4 ^
b ! 2 @ i। 3 3 : h v
4 H h 4 ।:4 3 w x @ Z । 3 J7 y H 2Y
z @ : 3 I3 ZM @ 4J । < 4 3
S 4@ f 7h 3 7 , 4@ f 7h 3 7 , J/ h 3 H
: @ @ ? । 45 <= > @ @ b -- "
। 45 <= > 4 @w C M @ 4J । J { A s Z
Y @ ? @ , Ys M gQ @ |: Y M
CM 3 @ @ Z । }~ 7 , 4 k< H -B
I3 •4 ? @ । <? A % € 4 |Z ।
% M :7 <? B @ • @ ।J ‚ 45
ƒ A 3 Z A < 4 „ @ < [ @ । b <V
, , } 8 9 8g@ ।: ^% 7 A … B C
GZ 4 †‡/ । 8 9 <= > :7 } Z <?
 evsjv‡`k †M‡RU, AwZwi³, A‡±vei 29, 2019 24287

@Z ^ Z? Z? B C (4Z : 2 / 23 7 4ˆ ) @
% 7 ‡ J ।; ‰ %S 4 4 4 H ^ B/,
M -a : 4 Š 4 4Z 3 H 4 ;
4 ।4 b <f @ }; 8 i। :4
<= > } m | H4 ।4 4 |4 h H4 Vc : 4 ‹
@ b। ‰I D/ D %VZ ! 3 Vc
‘ f ; ’ @ ।Œ }@ c 4 4 b 4Z, < 4 f
@ !. % : @ Ž -7- @ #. %। }• @ B C g@ 4 :4
@A 3 • ।

% ? %3 : 4 <= > 4 ~• ~• Z i। 4 A 3
@ `I @ | b। 4 B PB Z
@ b। Y ‘ PB J B a E /" !
, S H S `’ Z /" ' ।

".
". /0

< 4 @ % m 4b f 4b f 4 c n “ । 4 D
%I 3 4 c op J 4 B ” •x @ hY @ ।
% 4 c 3 4? : • x। E z x/
%VZ hY _7 S ; Z? ) 7 hY %M hY , Z
YC D ^7 p? । b – %k 4 %—- /— <= >
; ") ™ k l hY <g hY , Z YC D b |
< %—- /— g š <= > । : s @
^ – ›% b| | । :7 ™ k l hY 7 S 3
/0 @ ।

"." 3 :

3 3 : h v4 H h 4 ।:4 3 w
(< f B ) x @ Z । 3 J 7 y H 2Y z @ :
3 I3 ZM @ 4J । < 4 3
S 4@ f 7h 3 7 , 4@ f 7h 3 7 , J/ h 3 H
: @ @ ? ।
24288 evsjv‡`k †M‡RU, AwZwi³, A‡±vei 29, 2019

"., 2 4 :
"4 h4 3K S 2 4 œ b। 2 Z
ZM = n @ ? 3K • 4 4 । Z
2 4 4 4 |Z s_c ? | ? : %GD S @
? । 4 7 — Yž sB , %/ ( s Id ), @ | _ ,
Ÿ x@ , t M gQ 4 । = 2 2 9 H
s 4 op ।: 4 : 4 o p vf ? S
: % S । 2 h , Yž sB , 4 ¡ 7h : %k k 4 f
2 %2 = 2 4 @ । ? % D 4 :
B C 4 < @H ¢ S
£K Z ।Z 4 ¢ | ? : : Z 2 @ |
E¤ Y %? C 2 7 p s }p A D @ ।
:b| 2 D ^ M 4Z ।

".! 45 6 7 2:
@w C 4Z 4 % M ¥ %? M v @H Z "! vl
4 S ? : Z Q¦ s h • x (Stroke
may be defined as sudden Neurological deficit which persist for 24hrs or
patient may die within 24hrs which is non traumatic vascular origin)।

".- 8 9 :
8 7 } 9 ”
3K 8 §h (42 3 l :/ )?
।: ^9 ” ^ b¨ (%/ © 4 f 2 J&, 43 ª« , 4 f
2 J&), 4©f %J J/ f, 6 fl 2 & <f H 7 / Y ‘ Z ¬। :7
8 9 §h : 4Z } H op
S gD @ , 4 S S :7 §h -@ % 4Z ¬ @ Z । Z
® †‡/। % 4Z ¬ @H a Z Z? Z? B C 4Z - 2
23 7 ˆ Z 4 GD H I 3 3
।

".# ; :
; : h s 4 । :7 4 s %¯ @
@ Ž YC §h @ । ; S Vc S s
%¯ Id %/ œ ? । %/ J % gD 4?
 evsjv‡`k †M‡RU, AwZwi³, A‡±vei 29, 2019 24289

}• %—@ vf ।; _ ’S @ :< J ;
H4 f ; । S 3 < J ; 4 f ; 4?
y। < J ; x A s 4M ¤ 4 Y †_ „ E
@ । %k 4 f ; 4M ¤ 4 y % 4 ;
: -_7 b } 4M ¤ “ B C :h } †‡/ @
।:4 <= > } J/ @ Z : 3 _ @ |।
J op Z । ° @ | @ 4 f q Z । % D BH| @ E
< S : op A@ @ । ; 4 s
e S B C । %D ± D ; : h Z B C ।
; Z ¬। :h : h 8 •। %D ± Z ^
: ² • ।

,. M/ H Y F³ :
) /0 , 2 , 3 , 45 6 7 2, 8 9 :
; <= > 4 B C @ ;
) <= > 4 A 3 @ @ ;
) B C % D < E 4 †‡/ FE %?
@ ;
v) GD H I 3 J < @ ;
´) N 3K H B C L @ ।

!. PB Q 4 µ :
c 2s ¶ /0 , 2 , 3 , 45 6 7 2, 8
9 : ; <= > 4 s %?
%S J , D , S H GS @Z :
%V E _`D H % @ 4 a ·@
Z= Q @ ।

!. 4 Mu :
) Y‘ #h 4 <= > 4 ¸x Y %J /
@ %J : f< ;

) Y %J / @ %J u < ž
¹( ) ^ ? Zb7 b 7a >A @ Y B ,
4 Z 4 ;
24290 evsjv‡`k †M‡RU, AwZwi³, A‡±vei 29, 2019

) Y B , 4 Z ž ¹ ( ) ^ 4
h f º| > %V k4 । %V Y B
¸x Y %J / @ %J : f=
4B %? 4 A @ 7:Jh : ^ B C %? 4
A D ;
v) 4 Z 4 HY B ,4 Z 4Zµ?
I M %V , ^ 4B ;
´) M "-% : 4M ¤ :7 %VZ Y ‘ #h 4
B C A @ : B C L
@Z ।: c @ 4
4 @ B , % S J : I M 4B @ ;
-. Z: :
/0 , 2 , 3 , 45 6 7 2, 8 9 :
; <= > 4 <? @ PB Z:
g »„ ।
#. Q N M:
#. %? N M u A s/ L Q ;
#." %? 3 ¼ “ ‘ PB => 3
h’ : P B ½ S । b| 4 3 ¼4
ZB7 b7 H Q h, % s B ( Z= ) : 3 ¼
n H f h: B , 3 ¼
) h “ @ ।
¹. . M/ ; g@ :
b 4 M S 4 /0 , 2 , 3 , 45 6 7 2,
8 9 : ; <= > @ i। % ? %3 <= > 4 ~•
~• Z ।4 A 3 @ `I @ |। ‘ H @
: : – ¬4 <= > 4 <? @ k<
। %S J : c M / ; g@
A D g@ । ¸x 4 k www.welfaregrant.gov.bd : h
;3 ” @ A 9 @ ।Y 3 : 4 N M Z? Z?
= Y : A @ ® ।
 evsjv‡`k †M‡RU, AwZwi³, A‡±vei 29, 2019 24291

. <? @ :
/0 , 2 , 3 , 45 6 7 2, 8 9 :
; <= > B / 4 : - , ( e @ )
f @ । < ? %V o p/¥ M @ ¸x
B C L : %V @ %? 4? F ।
'. PB Q = :
'. ?› B ¾:
( ) ?› % ³7 D @ @ ;
( ) ž _`D H Y ‘ 4 <= > A s %g S @ ;
( ) [ @ Z .- : [ <b4 6@ ;
(v) }, `I, Y¶ ¿ H [ @ = V %g S @ ;
(´) /L, S , u, À , ` > , 4? iK
As = V %g S @ ।
'." <? @ u 4Z ¬ H :
'.". . /0 , 2 , 3 , 45 6 7 2, 8 9 :
; <= > 4 ¸x 4 c c 2s A D ¤H
4f) f @ Ás ¤ ’s S J < @
(< ¤ J %S J H 72 @ g@ @ )।
4 Z 4 3 4 s ।
. /0 4 4M ¤ Histopathology/Cytopathology/Bone Marrow
Report %k k 4f) f? @ ;
. 2 4 4M ¤ Acute Renal Failure %? Chronic Renal Failure
: <= > 2 7 4 i, 2 D ¿ i %?
2 D b: 4 B @ । s 7Y H
= h ¤ f? @ ;
. 3 4 4M ¤ 3 <Â g f : %k k
4f) f? @ ;
v. 45 6 7 2 <= > 4 Y x N / @ @
: MRI/CT Scan Report ? 3 @ ;
24292 evsjv‡`k †M‡RU, AwZwi³, A‡±vei 29, 2019

´. 8 9 4M ¤ Echo Cardiogram f: %k k 4f) f

? @ ;
B. ; 4 4M ¤ s @ Ž 7 © J
(Hemoglobin Electrophoresis) %k k Z / M f?
@ ;
'.".". B ¤/ 8 (4 f2 % J N / Jf ) ?
@ ;
'.".,. < : %? b : : 4 < ।
'.".!. J S D c 2s IM ? @ । 4 4M ¤
3 4 s ।
'.".-. < 7 a %S J / @ B C %? g@
@ b Y‘ @ ।
. <? @ k ?› b 7 p :
. . <? @ => h:
%V i -. H -." : h S %VZ ?› b7
A D g@ ।
.". B H Q <@ :
. %? %S J <? @ k
Q <@ D ,D As , ^ ,D ¤ ,4 x ,
J f : /4 @ N M % @ @
D 3 S „ B A D g@ ;
". / 0 , 2 , 3 , 45 6 7 2, 8 9 :
; <= > 4 ^ <? @ g@ <g@ <
S J < ¤a Z? Z? = ¸x ¤ ’s
a < ¸x Y Z / @ Z=
%J : g@ ;
,. ; JY ” / • H @ ¨
4 h ^ ZB7 b7 4 ।
Ys %S J 4 : @ B ,
%S J %? A D g@ ;
!. M "-% : <H #h 4 ? ¸x B C L 4?
F 4M ¤ < ।: c -., :
) h p > g@ ।
 evsjv‡`k †M‡RU, AwZwi³, A‡±vei 29, 2019 24293

.,. ?› b 7 H Ã = :
. ¸x Y %J Ä Y S u < -@ ?›
B ¾ %VZ 4Z ¬ < ¤ A D g@ 4
Z 4 ।4 h N %V %V
u = 4B 4 ।: c : h4 5 M
@ ;
". Y B u < -@ 4 ZB7 b7 H Q h 3
Y D ।4 h ž -( ) < ¤ -@ Z B 7
b7 <? @ u 4Z ¬ : h (<Vc — ¤ @)
%V ।4 Z : => : h 4 5 M
;
,. M "-% @ 3K B C L 4? F
। b| u< - @ %VÅ Ys %? @ F
Z । : c @ B ¸x 4 4B ।
:M¤ S Ys %? A ;
!. 4 @ : M/ ¸x Y %J / @
%J , 4 Y B Z , %S J H
< u ž " (:« ) ^ = £K ।
. 4Z <? @ Z :
. œ ; E ¤ “ @ ;
". N %k 4 < ? G S : Y F ³ g@ ;
,. < ? @ k œs Y@ g@ 7Æ @ ;
". <? @ S p :
. 4 A f2, < ÄH, Œ ‘‘ / 0 , 2 , 3
, 45 6 7 2, 8 9 : ; <= >
4 <? @ P B’’ 4 Ç Z : hB @
È @ ;
". :7 PB f FE %? 3K Q
@ B , %S J kQ । @ B 4
Z F । M "-% : k < A @
@ B u F %VZ S @ M ,
%g । Ys : =>
4 Ç @ %VÅ 4B 7G/ । % S J Ys 4B
4 A `: 4 Ç @ ;
24294 evsjv‡`k †M‡RU, AwZwi³, A‡±vei 29, 2019

,. 4 Z : PB Q k ‘‘ / 0 , 2 , 3 ,
45 6 7 2, 8 9 : ; <= > 4
<? @ P B, " '’’ 4 A : hB @
È @ ,Z 4 HY B ,4 Z 4Zµ?
IM B @ ;
!. %S J m 3 u F < 4 3
F Q 4 । %V = @ B
Y@ 4 Z %? D > ।
-. É| > œs 4 4 †‡/ F a :
7G/E 4B /%? g@ ।: S Ê > ? < /4
F Z 4 , z SY S @ B
@ ;
#. P Bh PB S A %VZ
¸x 4 f 4 A : h e @ È
: < ¤ Y‘ । < % u Ë @
/ z S % 33 4 A 4Z 4 @
È @ ;
¹. 4 Y B Q F u 4 h N %V
%VZ < , /I , ,A @ Ì ,
, D > %? Ì 4 H
Y B 4Zµ? I M Í 4 A ¸x 4
। A N M u %VZ ¸x 4 A @
%? 4 ® ;
[ . 7 © p (G2P) : P B %S @
।
,. FE %? 3 (4 , 3 ,%S J H ):
. ¸x %? b k FE % ? "-% %S J M
% x ¹-% %? #! 4 m %V 3 4
A @ 4 @ ;
". 4Z 4 Y /7Y. . 2 @ 4 < /4 H 4 4
m B 4 4 %V = F /4
n Z ;
 evsjv‡`k †M‡RU, AwZwi³, A‡±vei 29, 2019 24295

,. M "-% : %A %? 4 m B 4 B @
4 M % s F4 Z ;
!. 3K B C L B @ 4 M 4? F ।
!. M H- :
. : h Z
P B GLÎ H GB •3 B k M H
½ S €•¼ % ।‘ PB => 3 h’
P B GÏÐ /0 , 2 , 3 , 45 6 7 2,
8 9 : ; <= > 4 <? @ PB
3 , B : %S J
M H ½ S ।<? b 4 c: PB- @ :
- J J 3 › d / P B g@ @ ;
". 4 ZB7 b7 H Q h Z? Z? N M ^ @ B ,
%S J PB Q %g
4 ;
,. @B , %S J 4 ZB7 b7 H Q h
PB c ½ S : PB
Q %g 4 । b|, P B -@ Q
k “ ) h H 3 hH b Q
%g - a › A D g@ ;
!. %S J %? b 4 c º| > Q 4
।
-. . /0 , 2 , 3 , 45 6 7 2, 8 9 :
; 4 <? @ PB Q k “ h -@:
-. 4 ZB7 b7H Q h
-. . h Ñ :
. 4 %? % s4 3
". /4 4M ¤ 4 c S (: ) •
,. Y 4B ™ ( ) •
!. Y @ %J ( ) •
-. 3 / S •
#. Y B ,4 Z • B
24296 evsjv‡`k †M‡RU, AwZwi³, A‡±vei 29, 2019

-. ." h S:
. /0 , 2 , 3 , 45 67 2, 8 9 :
; <= > 4 <? @ M/ H% 7
u< ¤ -@ ?› B ” %VZ Z B 7- b 7
º| > @ @ ® ;
". < /% 3 Z Ò ;
,. Yž h Q HG 4 ;
!.. u< ž -( ) ^ Ã ;
-. h M (: ) 3 @ u< Ã
।
-.". ZB7 b7H n h
-.". h Ñ :
. % s B ( Z= ), 3
". B ( ), %S J •
,. Y B ( Z= ), •
!. B ˆ 3 / 3 S •
-. ¸x PB Y B , %S J •
#. @ B / @ B ( ), • B
-."." h S:
. M "-% : <H E < ¤ -@ Z B 7 b 7a
É| > %V ;
". %V , ^ @ B , %S J
4 @ ;
,. Z %3Z Ò ;
!. Yž h Q HG 4 ;
-. h M (: ) 3 @ ;
#. PB Q %g Z B H n S ।
 evsjv‡`k †M‡RU, AwZwi³, A‡±vei 29, 2019 24297
-., ) h:
-.,. h Ñ :
. B / B , 3
". @ B , %S J •
,. % s B ( Z= ), •
!. S Z S( B B ) •
-. %? 3 S (’Ó B B ) •
#. D 3 S (’Ó B B ) •
¹. I D/ H S (’Ó B B ) •
. B ( ), %S J •
'. — Ô 4 r 4 2 ‰ Õ c B C •
. @A D ,4 A :, S Z ,Œ •
. ’Ó B /Y B ( Z= ), • B
-.,." h S:
. /0 , 2 , 3 , 45 6 7 2, 8 9 :
; <= > 4 <? @ PB : S , f
H %g Z B ;
". Yž Z n HG ;
,. , M H- ;
!. PB Q YÖÎ • H ;
-. B C L %V c p > g@ ।
-.! PB ½ S => 3 h /0 , 2 ,
3 , 45 6 7 2, 8 9 : ; <= >
4 <? @ PB a › b - H › C
f S : PB Q S - p> ।
#. S , , S H M :
S , , S H M M ।7 a E
/" ! × @ । Ys S ·@ A D C
? ।
¹. : c 4 Ø 4
º| > ×@ ।
Ù <
B ।
24298 evsjv‡`k †M‡RU, AwZwi³, A‡±vei 29, 2019

Av‡e`‡bi ZvwiL: .................................. cwiwkó-1

GLv‡b cvm‡cvU©
eivei mvB‡Ri Qwe AvVv
w`‡q jvwM‡q Zvi
Y %J / @ %J Dci †M‡R‡UW
Kg©KZ©v KZ©„K
.......................................Y , mZ¨vwqZ Ki‡Z n‡e|
................................4 ।

welq: K¨vÝvi/wKWbx/wjfvi wm‡ivwmm/†÷ªv‡K c¨vivjvBRW/Rb¥MZ ü`‡ivM Ges _¨vjv‡mwgqvq

AvµvšÍ †ivMx‡`i Avw_©K mnvqZvi Rb¨ Av‡e`b|

g‡nv`q,
Avwg/Avgvi cyÎ/Kb¨v/†cvl¨/wcZv/gvZv GKRb K¨vÝvi/wKWbx/wjfvi wm‡ivwmm/†÷ªv‡K
c¨vivjvBRW/Rb¥MZ ü`‡ivM/_¨vjv‡mwgqvq AvµvšÍ †ivMx| Avwg mgvRKj¨vY gš¿Yvjqvaxb
mgvR‡mev Awa`dZi KZ©„K ev¯ÍevwqZ K¨vÝvi/wKWbx/wjfvi wm‡ivwmm/†÷ªv‡K c¨vivjvBRW/
Rb¥MZ ü`‡ivM/_¨vjv‡mwgqv †iv‡M AvµvšÍ †ivMxi Avw_©K mnvqZv Kg©m~wP n‡Z Avw_©K mnvqZv
†c‡Z B”QzK| wb‡¤œ hveZxq Z_¨vw` cÖ`vb Kiv n‡jv:
1. †ivMxi bvg (evsjvq) :.........................................................................
(RvZxq cwiPq cÎ/Rb¥ mb` Abymv‡i)
2. Patient’s Name (In English Capital Letters) :..................................................
(According to National ID Card/Birth Certificate)
Patient’s National ID No.

3. A_ev
Patient’s Birth Registration No.

4. †ivMxi Rb¥ ZvwiL (wLª÷vã):

5. †ivMxi eqm (Av‡e`‡bi ZvwiL):

eQi gvm w`b

6. wj½ (wUKwPý w`b): (K) bvix (L) cyiæl (M) wnRov

 evsjv‡`k †M‡RU, AwZwi³, A‡±vei 29, 2019 24299

7. ag© (wUKwPý w`b): (K) Bmjvg (L) wn›`y (M) †eŠ× (N) wLª÷vb (O) Ab¨vb¨
(D‡jøL Kiæb)...........................................................................................................
8. gvZvi bvg (evsjv) :............................................................................................
9. gvZvi bvg (Bs‡iRx eo Aÿ‡i) : ..........................................................................
10. †ivMxi gvZvi RvZxq cwiPq cÎ b¤^i :.....................................................................
11. wcZvi bvg (evsjv) :.............................................................................................
12. wcZvi bvg (Bs‡iRx eo Aÿ‡i) :...................................................................
13. wcZvi RvZxq cwiPq cÎ b¤^i ...........................:...................................................
14. †ivMxi Rb¥¯’vb: Dc‡Rjv/_vbv :................................. †Rjv :...................................
15. †ivMxi ˆeevwnK Ae¯’v (wUK wPý w`b): (K) AweevwnZ (L) weevwnZ (M) weaev/wecZœxK
(N) ¯^vgx/¯¿x c„_K (O) ZvjvK cÖvß/weevn wew”Qbœ|
16. †ivMxi ¯^vgx/¯¿xi bvg (evsjv) :................................................................................
17. †ivMxi ¯^vgx/¯¿xi bvg (Bs‡iRx eo Aÿ‡i) :...............................................................
18. †ivMxi ¯^vgx/¯¿xi RvZxq cwiPq cÎ b¤^i : ................................................................
19. †ivMxi e¨vsK GKvD›U b¤^i, e¨vsK I kvLvi bvg : (hw` _v‡K)......................................
20. †ivMxi eZ©gvb wVKvbv :

20.1 evmv/†nvwìs bs :
20.2 iv¯Ívi bvg bs :
20.3 eøK/†m±i/†gŠRv/gnjøv/GjvKvi bvg :
20.4 MÖvg :
20.5 WvKNi :
20.6 †cv÷ †KvW :
20.7 IqvW© b¤^i :
20.8 BDwbqb/K¨v: †ev: :
20.9 Dc‡Rjv :
20.10 _vbv :
24300 evsjv‡`k †M‡RU, AwZwi³, A‡±vei 29, 2019

20.11 wmwU K‡cv©‡ikb/†cŠimfv :

20.12 †Rjv :
20.13 †`k : evsjv‡`k
20.14 †dvb bs :
20.15 †gvevBj bs :
20.16 B-†gBj :

21. bwgwb msµvšÍ Z_¨ :

21.1 bvg :
21.2 wcZv/gvZvi bvg :
21.3 RvZxq cwiPqcÎ b¤^i :
21.4 †ivMxi mv‡_ m¤úK© :
21.5 †gvevBj b¤^i :

22. †ivMxi ¯’vqx wVKvbv :

22.1 evmv/†nvwì bs :
22.2 iv¯Ívi bvg bs :
22.3 eøK/†m±i/†gŠRv/gnjøv/GjvKvi bvg :
22.4 MÖvg :
22.5 WvKNi :
22.6 †cv÷ †KvW :
22.7 IqvW© b¤^i :
22.8 BDwbqb/ K¨v: †ev: :
22.9 Dc‡Rjv :
22.10 _vbv :
22.11 wmwU K‡cv©‡ikb/†cŠimfv :
22.12 †Rjv :
 evsjv‡`k †M‡RU, AwZwi³, A‡±vei 29, 2019 24301

23. †ivMxi †ckv :......................................................................................................

24. †ivMxi/Awffve‡Ki evrmwiK Avq :.........................................................................
25. †ivMxi/Awffve‡Ki Rwg/m¤ú‡`i cwigvY :...............................................................

GZØviv cÖZ¨qb Kiv hv‡”Q †h, Dc‡i cÖ`Ë Z_¨vw` Avgvi Rvbv g‡Z mwVK|
........................................

Av‡e`bKvixi ¯^vÿi

(†ivMxi eqm Av‡e`‡bi Zvwi‡L 18 eQ‡ii Kg n‡j wcZv/gvZv/ˆea AwffveK Av‡e`b Ki‡Z
cvi‡eb)|
Av‡e`bKvixi bvg :..................................................................................................
†ivMxi mv‡_ m¤úK© :...................................................................................................
Av‡e`bKvixi gvZvi bvg :..........................................................................................
Av‡e`bKvixi wcZvi bvg :.........................................................................................
Av‡e`bKvixi RvZxq cwiPq cÎ bs :............................................................................
Av‡e`bKvixi †gvevBj bs :........................................................................................

mshyw³ :
1. we‡klÁ Wv³vi KZ©K
„ cÖ`Ë mswkøó †iv‡Mi cÖZ¨qb c‡Îi g~jKwc (wbw`©ó Q‡K)|
2. †iv‡Mi e¨e¯’vcÎ msµvšÍ cÖ‡qvRbxq KvMR c‡Îi (†M‡R‡UW Awdmvi KZ©K
„
mZ¨vwqZ) d‡UvKwc|
3. RvZxq cwiPq cÎ/Rb¥ mb‡`i (†M‡R‡UW Awdmvi KZ©„K mZ¨vwqZ) d‡Uv Kwc|
4. 02 (`yB) Kwc Qwe (†M‡R‡UW Awdmvi KZ©„K mZ¨vwqZ) hv `iLv‡¯Í Mvg w`‡q †c÷
Kiv Qwei AwZwi³|
5. †ivMx KZ©„K cÖZ¨qb cÎ|
6. *†ivMxi eqm Av‡e`‡bi Zvwi‡L 18 eQ‡ii Kg n‡j wcZv/gvZv/ˆea AwffveK
Av‡e`b Ki‡Z cvi‡eb, †m‡ÿ‡Î Av‡e`bKvixi 02 (`yB) Kwc Qwe (†M‡R‡UW
Awdmvi KZ©„K mZ¨vwqZ)|
24302 evsjv‡`k †M‡RU, AwZwi³, A‡±vei 29, 2019

cwiwkó-2 (K)
(mswkøó we‡klÁ Wv³vi KZ©K
„ K¨vÝvi/wKWbx/wjfvi wm‡ivwmm/†÷ªv‡K c¨vivjvBRW/Rb¥MZ
ü`‡ivM Ges _¨vjv‡mwgqv †iv‡Mi cÖZ¨qb cÎ)

GB g‡g© cÖZ¨qb Kiv hv‡”Q †h, Rbve/†eMg :.................................................

wcZv/¯^vgx :.............................................................................................

gvZv :....................................................................................................

wVKvbv : ................................................................................................
............................................................................................................
............................................................................................................
wZwb GKRb ....................................................................................... K¨vÝvi/wKWbx/
wjfviwm‡ivwmm/†÷ªv‡Kc¨vivjvBRW/Rb¥MZ ü`‡ivM Ges _¨vjv‡mwgqv †iv‡M AvµvšÍ †ivMx|

[we. `ª. cwi¯‹vi fv‡e †iv‡Mi bvg I aib D‡jøL Ki‡Z n‡e, Ab¨_vq Av‡e`b evwZj n‡q hv‡e]
.…………………………
(¯^vÿi, ZvwiL I mxj)

Wv³v‡ii †iwR‡÷ªkb bs
:..........................
†dvb : .................................................
†gvevBj : .............................................
Av‡e`bc‡Îi mv‡_ cÖ‡qvRbxq KvMR cÎ:
K. K¨vÝvi/wKWbx/wjfviwm‡ivwmm/†÷ªv‡K c¨vivjvইজ/Rb¥MZ ü`‡ivM Ges _¨vjv‡mwgqv
†iv‡M AvµvšÍ †ivMx‡K Aek¨B †iwR÷vW© wPwKrmK KZ©K „ cÖZ¨vwqZ n‡Z n‡e;
L. K¨vÝvi †iv‡Mi †ÿ‡Î Histopathology/Cytopahtology/Bone Marrow Report ev
Ab¨vb¨ †U÷ wi‡cvU© _vK‡Z n‡e|
M. wKWbx †iv‡Mi †ÿ‡Î Acute Renal Failure A_ev Chronic Renal Failure G AvµvšÍ
WvqvjvBwmm †mev wb‡”Q, wKWbx cÖwZ¯’vc‡bi cÖ¯‘wZ wb‡”Q A_ev wKWbx cÖwZ¯’vcb K‡i‡Q
Ggb †ivMx‡`i‡K we‡ePbv Ki‡Z n‡e| i‡³ BDwiqv I wµ‡qwU‡bi gvÎvi wi‡cvU© _vK‡Z n‡e|
N. wjfvi wm‡ivwmm †iv‡Mi †ÿ‡Î wjfv‡ii Avëªvm‡bvMÖvg wi‡cvU© _vK‡Z n‡e|
O. †÷ªv‡K c¨vivjvBRW AvµvšÍ †ivMx‡K wbD‡ivjwR÷ KZ©„K cÖZ¨vwqZ n‡Z n‡e Ges
MRI/CT Scan Report _vK‡j fvj nq|
P. Rb¥MZ ü`‡iv‡Mi †ÿ‡Î Echo Cardiogram wi‡cvU© _vK‡Z n‡e|
 evsjv‡`k †M‡RU, AwZwi³, A‡±vei 29, 2019 24303
Q. _¨vjv‡mwgqv †iv‡Mi †¶‡Î i‡³i wn‡gv‡Møvweb B‡jK‡Uªv‡dv‡iwmm (Hemoglobin
Iectrophoresis) ev Ab¨vb¨ cÖ‡hvR¨ cix¶vi wi‡cvU© _vK‡Z n‡e|
cwiwkó-2 (L)
cÖZ¨qbcÎ

Avwg/Avgvi cyÎ/Kb¨v/†cvl¨, ....................................................................

wcZv/¯^vgx-.............................................., gvZv- ....................................
MÖvg- ....................................................., WvKNi-..................................
_vbv/Dc‡Rjv- ....................................., †Rjv- ............................GB g‡g©
cÖZ¨qb KiwQ †h, K¨vÝvi, wKWbx, wjfviwm‡ivwmm, †÷ªv‡K c¨vivjvBRW, Rb¥MZ
ü`‡ivM Ges _¨vjv‡mwgqvq wPwKrmv LiP eve` miKvi n‡Z †Kvb Avw_©K mnvqZv
MÖnY KiwQ/Kwi bvB|

.............................................
Av‡e`bKvixi ¯^vÿi
(†ivMxi eqm Av‡e`‡bi Zvwi‡L 18 eQ‡ii Kg n‡j wcZv/gvZv/ˆea AwffveK Av‡e`b Ki‡Z
cvi‡eb)|

Av‡e`bKvixi bvg :....................................................................................................

Av‡e`bKvixi gvZvi bvg :..........................................................................................

Av‡e`bKvixi wcZvi bvg :..........................................................................................

Av‡e`bKvixi RvZxq cwiPq cÎ bs :............................................................................

Av‡e`bKvixi †gvevBj bs :........................................................................................

†gvt ZvwiKzj Bmjvg Lvb, DccwiPvjK, evsjv‡`k miKvix gy`ªYvjq, †ZRMuvI, XvKv KZ…©K gyw`ªZ|
†gvt Avãyj gv‡jK, DccwiPvjK, evsjv‡`k dig I cÖKvkbv Awdm, †ZRMuvI,
XvKv KZ…©K cÖKvwkZ| website: www.bgpress.gov.bd