OPD CASE FILE FEMALE

Name Age

Phone

Address

Reg.No. Date Rcpt. No.

Uro-Health ClinicUro-Health ClinicUro-Health Clinic2/503, Ground floor, Vikas Nagar, Lucknow-226 022

Qksu % 0522-2739099, 2739499, 3207964, eks- % 9235401984

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Dr. Divakar DalelaMBBS, MS (Surgery),MCh (Urology), FICS (Urology), FAMS (Urology)

Consultant Uro Surgeon

Professor & Former HeadDept. of Urology, KG Medical University, Lucknow

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E-mail : drdalela24@gmail.com

Name : Age:

Uro-Health ClinicProf. D. Dalela, MS, MCh

Aforesaid information is not valid for medical-legal purposes.

Main Diagnosis

Initial Plan

Co-morbidities

Dates of Previous Operations/Procedures

Histopathalogy

Referred by :

With acknowledgments

Clinical HistoryLower Urinary Tract Symptoms

Thin Stream

Slow Stream

Hesitancy

Terminal Dribble

Incomplete voiding

Urinary retention

Previous Cathet.

Diurnal Freq.

Nocturia

Urgency

Urge Incont.

Dysuria

Urinary Burning

Bed wetting

Upper Urinary Tract Symptoms

Flank Lump

Oliguria/anuria

Graveluria

Flank Pain

Fever

Oedema

Haematuria

Pyuria

Chyluria

Constipation

Frequent Stools

Backache

Misc. Symptoms

Previous Illnesses/Hospitalization

Family History

Addictions Menstrual Status

Prof. D. Dalela, MS, MCh

Aforesaid information is not valid for medical-legal purposes.

Dysmenorhea

Dyspareunia

Infertility

Vaginal dryness

Vaginal discharge

Menorhagea

Genital Symptoms

Previous Medication

Name & Dose of Drug Taking Since Prescribed by

Drug Allergies

Clinical Examination

Name of Drug Type of Allergies

Prof. D. Dalela, MS, MCh

Aforesaid information is not valid for medical-legal purposes.

Pulse :

Edema :

BP :

Weight :

Abdomen

Investigations ChartBlood Group HBsAg HCV HIV

Prof. D. Dalela, MS, MCh

B. Sgr. P

Date

Date

Hb

TLC

DLC

PT

APTT

BT/CT

B. Sgr. F

B. Sgr. R

Creatinine

Uric Acid

Na

S Calcium

S PO4

S PTH

Bilirubin

Alk Phos

SGPT

Total Pro t.

Albumin

S.TSH

S. T3/T4

SGOT

K

Aforesaid information is not valid for medical-legal purposes.

USG

Date UT Uterus/Ovaries PVRU

Prof. D. Dalela, MS, MCh

Aforesaid information is not valid for medical-legal purposes.

URODYNAMICS

IVP

MCU

CYSTOSCOPY

CT/MRI

UROFLOW

Date Volume PFR AFR Time

CARDIO RESPIRATORY

Date%

Left Kidney Right Kidney

Drainage % Drainage

RENAL SCAN

Prof. D. Dalela, MS, MCh

Date Organism Main SensitivityDate Pus Cell RBC,s Albumin Chy/Trig

Aforesaid information is not valid for medical-legal purposes.

Urologic Diagnosis

Upper Tract Status

Lower & Genital Tract Status

Urinalysis Urine C/S

Aforesaid information is not valid for medical-legal purposes.

Progress & Treatment Prof. D. Dalela, MS, MCh

Clinical Progress

Plan

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Clinical Progress

Plan

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Aforesaid information is not valid for medical-legal purposes.

Progress & Treatment Prof. D. Dalela, MS, MCh

Clinical Progress

Plan

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Clinical Progress

Plan

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Aforesaid information is not valid for medical-legal purposes.

Progress & Treatment Prof. D. Dalela, MS, MCh

Clinical Progress

Plan

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Clinical Progress

Plan

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Aforesaid information is not valid for medical-legal purposes.

Progress & Treatment Prof. D. Dalela, MS, MCh

Clinical Progress

Plan

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Clinical Progress

Plan

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Aforesaid information is not valid for medical-legal purposes.

Progress & Treatment Prof. D. Dalela, MS, MCh

Clinical Progress

Plan

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Clinical Progress

Plan

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Aforesaid information is not valid for medical-legal purposes.

Progress & Treatment Prof. D. Dalela, MS, MCh

Clinical Progress

Plan

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Clinical Progress

Plan

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Visit Record

Date S.No. Rcpt. No. Signature