INITIAL PATIENT ASSESSMENT IN OPD

Name : _________________ Age : Sex : Date :

Date of Birth : ______/_____/_____ UHID No. : Address

Weight : _____ KG Height : _____ CM BMI : Weight in kg/height in meter square

ALLERGIES Provisional Diagnosis ……………………..

PRESENTING COMPLAINTS

RELEVANT PAST HISTORY :

MILESTONES

FAMILY HISTORY

NUTRITIONAL ASSESSMENT & DIETARY HISTORY

Calculate BMI Score Normal 0
Under Weight <18.5 2 Less intake 1
Normal 18.5-25 0 No intake of foods since past 5 days 2
Over Weight 25-30 1 Acute illness 3
Obese 30-39 2 HEALTH STATUS AS PER BMI
Morbid Obesity >40 3 Healthy Underweight
Overweight Obese

PHYSICAL EXAMINATION/VITALS:

Anaemia Cyanosis jaundice JVP clubbing Oedema feet

Lymphadenopathy
Temperature :
Heart Rate :
Blood Pressure :
Respiratory Rate :
SPO2 :
Pain Assessment (Faces Scale) :

SYSTEMIC EXAMINATION
Ears :
Nose :
Throat :
Eyes :

CONDITION OF ORAL HEALTH :

Teeth :
a) Missing :
b) Caries :
c) Filled :

Gums :
Tongue :
Overall Oral Hygiene :
a) Good :
b) Fair :
c) Poor :
d) V. Poor :

SKIN

RESPIRATORY SYSTEM :
Chest Movements Symmetrical Asymmetrical
Breath Sounds Vesicular Bronchial
Adventitious sounds Crepts Ronchi
Signs of Respiratory Distress
Stridor
Grunting
Retractions

CARDIOVASCULAR SYSTEM :
Size, Position, Impulse of Heart :
Heart Sounds S1 S2 Added sound Murmur :
All Pulse :

ABDOMEN :

Consistency :
Liver :
Spleen :
Any lump :
Tenderness :

CENTRAL NERVOUS SYSTEM:

Consciousness :
Neurological Deficit :
Tendon reflexes :
Planters :

GENITOURINARY SYSTEM :
Hydrocele : _______________________ Kidney :
Varicocele : _______________________ h/o Calculi :
Venereal disease : _______________________

PREVIOUS INVESTIGATION/ NEW INVESTIGATION:

FINAL DIAGNOSIS

TREATMENT/PRESCRIPTION :

DIET AS RECOMMENDED BY :

Doctor :

Dietician :

Immunization Status
Age Birth 6 weeks 10 weeks 14 weeks 16-18 months 4-5 Years
BCG Birth
O.P.V. Birth 1st 2nd 3rd Booster – 1 Booster - 2
D.P.T. 1st 2nd 3rd Booster – 1 Booster - 2
Hepatitis B Birth 1st 2nd 3rd Booster at
6 months
Hib 1st 2nd 3rd Booster
Measles 1st dose booster
MMR 9 month Booster at 4-6 years
15 months
JE 12 month Booster at
13 months
Influenza (IIV) 6 month 7 month Booster Every
Year
Typhoid 9-10 month Booster at
Conjugate 2 years
PCV 1st does 2nd 3rd Booster
Rota Virus 1st does 2nd 3rd
Varicella 15 month Booster
Hepatitis A 12 month Booster
Tdap/TD 10 years
Td/TT 16 years
HPV 9 year onward
girls
Meningococcal 9 month in
Conjugate high risk group
vaccine – 1

FOLLOW UP

DANGER SIGNS

SIGNS OF LIFE THREATENING CONDITION

In case of Emergency Contact :

Doctor Signature with Name