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