1.

Name:-
2. Age:-
3. Address:-
4. Occupation:-
5. Economic status:-
6. Food Habit:-

Physical Examination:-

 Temperature-

 Respiration-

 Pulse-

 BP-

Skin:- Normal/Wrinkled/Rash/Dry

Eye:- Normal/Discharge/Contract

Teeth:- Normal/Carries/Denture

Nose:- Normal/Discharge

Mouth:- Normal/Sore/Swelling/Difficulties

Neck -Gland:- Palpable/Non-Palpable

Breast:- Normal/Discharge/Lumpy

Problem in related to activity of daily living: -

Standing:-

Walking:-

Digestion:-
 Defecation:-

Urination:-

Sleeping:-

Any other problems: -

Significant health habit:- Smoking/drinking/nothing
Past history of illness:-
Present history of illness:-

Advice: -

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10.

Signature of sister tutor Signature of student