Medical Report

FIRST NAME

SURNAME

DATE OF BIRTH

GENDER

CASE NO.:

DATE

Current complaints (Symptoms and signs)

PHYSICAL EXAMINATION

Temperature (°C)

Sp02 (%)

Heart Rate

BP (mm)

Findings

X-RAYS

YES

U/S

YES

CT SCAN

YES

MRI SCAN

YES

Doppler (Triplex)

YES

Laboratory tests

YES

ECG

YES

other

Findings

Specialists & Consultations

Specialists

Comments

DIAGNOSIS

TREATMENT

Recommendations and discharge instructions

I declare that all information, medical history, answers and documents given in connection with this claim are true, correct and complete to the best of my knowledge and belief. I was informed that this is a private medical practice facility and I give my consent and authorization for the treating doctor to conduct/execute my medical examination/treatment in compliance with the code of Medical Practice and Ethics and for the bene t of my health condition. I authorize my GP and Galenus Clinic to disclose medical information relating to my records and medical condition so that I can bene t from health cover through my insurace policy.

PATIENT'S SIGNATURE

DOCTOR'S SIGNATURE