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Get Form Hihospital Treatment Rev 72009

S from all the hospitals duly filled in are to be submitted. If admission to ICU is for more than one spell, details of such different admissions to be given separately) Name of the Patient Age In Patient No. Date of Admission in hospital Date of Discharge from hospital Date of Admission in ICU Date of Discharge from ICU Name of Attending Doctor / Surgeon Diagnosis Whether the present ailment/disease is a complication of any preexisting condition that the patient is suffering from? Past illness.

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