เลขที่บัตรผู้ป่วย :
ชื่อ - สกุล (Name - Surname) :
อายุ (Age) :
การวินิจฉัยโรค ระดับผู้ป่วย
การตรวจร่างกาย (PE)
สภาพทั่วไป (GA) :
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