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Name of the Patient :
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OPD
Address
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Findings of Findings ~f .
Investigations : Complaints of the Pat~ 9-1//-- V Investigations .
HbM RPR/VDRL
7
1-H-b---+--- ' ~ HBsAg
HIV 1&2
TLC
DLC
e" M, ,)') A Anti HCV Ab
PC . ' -i-===::::=_----t----7
Sputum/
CBC Provisional Diagnosis :
Pus for AFB

ESR RBS
ABO Rh

0
BL Sugar
CM
Advice: Smear for
Rec RTI/STI

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AEC
l - Gram
. staining
TRBC 1----+-----,
. r)?c}/t,. VIA
BTCT 1------t------,
..... 't- , rk 39 for
SickT

MP sl
q2 ,
MPR

UPT
~t: -6 ,8-/ TB Mtx
URINE spl

URINE R/M

STOOLR/M
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STOOLOcc.
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Semen
Analysis
U)MP

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Den. NSl Ag

Signa re Full Name of the Doctor

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