Guidelines for Operationalising A Primary Health ... - NRHM Manipur

Annexure-2Referral SlipRegistration Number:Name of Patient:Age:Address:Date and Time:Sex:Reason for referral/Diagnosis:History:Examination (at the time of referral):General condition:Pulse:BP:Temperature:Systemic Examination:Investigations done (if any with date and report):Treatment given (Mention dose, route, date and time of administration):1.2.3.4.5.Referred to (Name and/or location of Health facility):____________________________________________________________(Signature & Name of Medical Officer)Name of PHC, District(States may make colour coded referral slips for different Districts/PHCs)20