FORMAT FOR MEDICAL RECORD (see regulation 3.1)

Name of the patient :

Age :

Sex :

Address :

Occupation :

Date of 1st visit :

Clinical note (summary) of the case:

Prov : Diagnosis :

Investigations advised with reports:

Diagnosis after investigation:

Advice :

Follow up

Date: Observations:

Signature in full …………………………. Name of Treating Physician