Referral to Vaccine:

General Examination ☐ Yes ☐ No

File # ZF11672 Pts Name:  ‫وضحى محمد نصر‬ Date: 4/22/2020

Address 24 ‫ – منزل‬14 ‫ – شارع‬8 ‫مخيم الزعتري – قطاع‬

Phone 1 0790680295 Phone2 NA
Current Age 68
B.P  NA Temp  NA Health Education: ☒ PHC ☐ RH
H.R  NA Weight  NA
H.C  NA H.B  NA Nurse Procedure: Pt not present
F.B.S  NA R.B.S  NA

Hb1ac  NA     

Case is stable Yes

Chief Complain: HTN Code: 99

6

☐ New Case ☒ Follow Up

History:
68 y/o with hx:
HTN

Physical Exam:

Patient not presented, but we were contacted with her by phone due to curfew, her vital sign on
last visit was normal, the patient status is stable, and no other issues according to her health
status.
Assessment & Work up: NCD – Lifestyle Advice
☐ Diet
☐ Exercise
☐ Smoking
☐ Other

Diagnosis:

Patient status is stable, medications are given, continue home monitoring and refer to our clinic in case of
happening any problems.

Prescription ID Number E0002015

SN Code Medication Dose Quantity Notes
1. A13 Amlodipine 5mg tab 1*2 60
2. B11 Bisoprolol 5mg 1*1 30
3. P2 Paracetamol 500mg 1*2 24
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Referral ☐ Yes Cause of Referral with code: Referral to with code:
☒ No

Dr. Name: Hazem Signature:

Date:22/04/2020