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Application for MEDICAL TREATMENT ABROAD Original for Medical Authority and duplicate for Bangladesh Bank -------------------------------------------------------------------------------------------------Dhaka.
** Consultant specialist means a doctor who got post graduate qualification in the particular subject of ailment to the patient.
From- 2 To be filled by the consultant specialist who was been treating the patient and is advising further treatment outside the country. The particular should be completed as possible in respect of the system only the relevant finding should be recorded.
1. Particular of the patient. Name- Sex Religion Chief complain-
General Fill Nutrition Anaemia Jaundice Oedema
Cardiovascular Heck Veins Heart sound Any other finding if any
Respiration rate and rhythm type Movement of chest Tracheas Bronchial framitus
Swallowing Any other in mouth Any conscious swelling over abdomen Liver Spleen
1. I.N.P 2. Genital, Urinary system 3. Swelling in the Renal Area
Page-2 Tenderness growth Palpable growth Any other findings
Menstrual history................................................Regular/Irregular if So Duration Uterus- Enlarged or not- Alteration of cervix Tumor seen/ palpated
Nervous System Mental Condition Higher cerebral function Speech Spine Movement Flexion Extension Rotation Spinal nervous autosensory Reflexes Locomotors Bone condition Gait
EYE Vision Paresis Diplopia Squint Nystigmus Pupil condition Any Ulcer/ Tumour Nature of Tumour Other special finding if any. Pupil Other special findings if any Page-3
Vestibular Giddiness / Dizziness. Growth if any nature of growth Other findings, if any
Condition of Muscles Weakness Wastage Response to Electric stimuli Uloeration/ growth
Pathologist Blood T.C D.C. E.S.R. Ph% WR V.D.R.L. C.F.T Kahn test Blood sugar Fast/ 1.5 hours after meal Serum protein Serum cholesterol Serum Uric Acid Blood Culture Stool Microscopic Urine Chemical Microscopic culture C.S.F. Chemical Serological WR CFG
Culture Positive Negative
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B.C. other investigation X-Ray Chest PA/lat View I.V.C I.V.C. Endoscopic findings Eystigram Endoscopic examination X-Ray of skull X-Ray spine Renal function test Liver function test Angiographic examination Biopsy report required-
N.B.The investigation should be in relation to the diseases only for which the patient require to:-
Declaration the consultants specialist I Dr............................................................... ...............( Qualification)................................. ..........................................................do here by declare that Mr./Mrs./Miss................................ ................................................ address............................................................................................ ..............................................................has been suffering from.................................................... .........................................since...................................... There is no scope for further essential life saving investigation and treatment required for its improvement in Bangladesh, I advise him for further treatment in..............................................................country.
Signature in full of the
Name (Block letter).................................................. Reg.No...................................................................... Place.............................
PROCEEDING OF MEDICAL BOARD
Assembled at................................................................................................................................ .......................................................................by the order of the Director General of Health Services. Govt. of Bangladesh for the purpose of assessing Foreign Exchange requirement of................................................................................................................................................... ........................................................................................................................................................... The Board assembled by pursuant of order No............................................................................ ............................................................recommended / do not recommended Foreign Exchange ...................................................................................................................................................... Diagnosis..................................................................................................................................... ......................................................................................................................................................
1. Chairman............................................... 2. Member.................................................... 3. Member................................................
Age.............................. Height.......................... Weight......................... Identification Mark......................................................................................................... Clinical Finding.................................................................................................................. History.................................................................................................................................. .
Important findings found by the Foreign Exchange Medical Board gist of the Board's findings of examination of the patient should be recorded. Tentative investigation suggested to be carried out abroad Tentative treatment which may done abroad to be suggested.
OPINION OF THE FOREIGN EXCHANGE MEDICAL BOARD
In the opinion of the medical board the ailment from which Mr./Mrs./Miss...................... ............................................................................................................................................ suffering from............................................................................................................................... ...................................................................................................................................................... No further essential life saving facilities are available for investigation and treatment in Bangladesh and as such it is recommended that Mr/Mrs/Miss.................................................... ...........................................should proceed to...................................................................for further investigation and treatment. As such for the above purpose the Medical Board recommended release of Foreign Exchange of............................................................................ The Board also recommended one attendant to go with the patient for whom release of Foreign Exchange of ..............................................................................also recommended. Name in Block Letter Signature with Seal
1............................................................... Chairman.................................................................
2............................................................... Member...................................................................
3................................................................ Member.................................................................. |