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IBN SINA HOSPITAL
l1 House No.# 68, Road# 15/A

···-·
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IBN SINA
.._ .. ~ .- -
Dhanrnondi RJA. Dhaka - 1209
Phone : 02-55029101-9 Date :

Name : ................... ~·~······ ~····


....................... Age: ... Sex :.. [ ....... .
C'C:

cf§ I

O;E:
a~ :
I

Pulse:

Temp :

BP:

Heart:

Lungs:

P/abd:

Anaemia:

Jaundice:

Edema:

Dehydratio. :

Body Wt :

RBS:

Blood Group :

P/D:

Name
Signature
Designation (Seal)

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