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TN CMCHIS Proforma FOR USG CR MRI

This document is a proforma that doctors must fill out when requesting diagnostic tests for a patient. It requires information about the patient like name, age, sex, contact details and ID numbers. It also requires details about the referring doctor and hospital. The proforma collects clinical history, examination findings, provisional diagnosis, and remarks. X-ray reports must be attached for CT or MRI of the spine. The referring doctor must sign with their hospital seal.

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umapathy
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895 views1 page

TN CMCHIS Proforma FOR USG CR MRI

This document is a proforma that doctors must fill out when requesting diagnostic tests for a patient. It requires information about the patient like name, age, sex, contact details and ID numbers. It also requires details about the referring doctor and hospital. The proforma collects clinical history, examination findings, provisional diagnosis, and remarks. X-ray reports must be attached for CT or MRI of the spine. The referring doctor must sign with their hospital seal.

Uploaded by

umapathy
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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Date

Proforma to be filled up by the requesting doctor for the diagnostic test


((All columns are mandatory, please tick appropriate investigation)
USG CTMRI
 Name of patient:_______________________________ Age:______ Sex:__________
 Patient Details
Contact No: ________________________________________________________
Smart Card No.: ____________________________________________________
Ration Card No.:____________________________________________________
 Hospital (Referred from): ___________________________________________________
District: _________________________________________________________________
 Referring Doctor’s Name:____________________________________________________
Contact No./Mobile No.: __________________________________________________
 Referring doctor qualification, hospital attached, sign and seal with Reg No.: ________
_______________________________________________________________________
DETAILED CLINICAL HISTORY:

COMPLETE CLINICAL EXAMINATION:


INSPECTION

PALPATION

AUSCULTATION

PERCUSSION

X-RAY SPINE REPORTS TO BE ATTACHED SHOULD BE MADE MANDATORY FOR CT/MRI SPINE

PROVISIONAL DIAGNOSIS:

REMARKS

NAME OF THE DIAGNOSTIC CENTER: _______________________________________________


DC DISTRICT:___________________________________________________________________
DC CONTACT NO.: _______________________________________________________________

(Signature of referring doctor with hospital seal)

KINDLY TAKE XEROX, OR DOWNLOAD FROM WEB, OR CAN BE TYPED FOR FURTHER COPIES

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