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Discipline

: General

Sub Discipline

: test

Document Title

: Dermatology Leprosy Contact

Encounter Type

ClinicDaycareInpatient

Name Of Index Case

Classification Of Index Case

PBMB

Name Of Contact

Ic No

Gender

MaleFemale

Age

Race

Address

Telephone No

Relationship To Index Case

Clinical Examination

Clinical Examination Number

Skin

Lesion

YesNo

Reduce Sensation

YesNo

Hipopigmented

YesNo

Others

Physical Deformity

YesNo

Eyes

Visual Acuity

Can Close Eyes

YesNo

Others

Hand

Claw Hand

YesNo

Others

Foot

Foot Drop

YesNo

Others

Nerves

Paraesthesia

YesNo

Others

Plan

SIGNATURES

Notes Component

SIGNATURES

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