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Here is the form filled in with all the information extracted from the image. Fields already completed are marked, and blank fields are noted:
OSCAR MEDICAL CENTER
(आम आदमी का अस्पताल)
SECTOR-25, PANCHKULA | Tel: 90538-93331
REQUISITION FOR HISTO PATHOLOGICAL EXAMINATION OF TISSUES
Header (Green Background)
| Field | Value |
|---|---|
| UHID No. | 4984 |
| IP No. | 880 |
| ICD | (blank) |
Patient & Consultant Details
| Field | Value |
|---|---|
| For OPD cases referred from outside | (blank) |
| Name | Ram Kanti |
| Age | 66 |
| Sex | F |
| MRF OPD / IPD | 880 |
| Consultant | Dr. Amrinder |
Processing Reference
| Field | Value |
|---|---|
| Date recd. | (blank) |
| Reported on frozen | (blank) |
| Reported on paraffin | (blank) |
| Surg. Path No. | (blank) |
Nature of Specimens
- (blank)
- (blank)
- (blank)
- (blank)
For Ob. / Gyn Cases
| Field | Value |
|---|---|
| Menses Onset | (blank) Yrs |
| Come Every | (blank) Days |
| Last | (blank) days Character |
| LMP | (blank) |
| Gravida | (blank) |
| Para | (blank) |
| Menopause | (blank) Yrs age |
| Hormone therapy | (blank) |
Clinical & Diagnostic Information
- Clinical Data (physical signs, X-ray/Ultrasound findings): (blank)
- Relevant Laboratory findings: (blank)
- Operative findings and procedure: (blank)
- Clinical Diagnosis: (blank)
- Postoperative Diagnosis: (blank)
- Previous Histopath / Cytopath Diagnosis, if any & Ref. No.: (blank)
Footer
| Field | Value |
|---|---|
| Staff Nurse | (signature present, name blank) |
| R.M.O. | (blank) |
| Unit Incharge | (blank) |
The form has been partially filled with the following confirmed data:
- Patient: Ram Kanti, Female, Age 66
- UHID No.: 4984 | IP/MRF No.: 880
- Consultant: Dr. Amrinder
All remaining fields (specimens, clinical findings, diagnosis, lab results, OB/GYN details, and signatures) are blank and need to be completed by the treating physician or hospital staff. Would you like help drafting content for any of the blank fields?
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