- Organ:


Head & neck

Normal
Abnomal

Heart

Normal
Abnomal

Breast

Normal
Abnomal

Lung

Normal
Abnomal

Abdomen

Normal
Abnomal

lower limbs

Normal
Abnomal

General Condition


- Vaccination ( التطعيمات):


T.T.

Yas
No

Date of last dose


others

Yas
No

If yas (specify)