Fill Report by FARUK

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Report Text (Edit Titles here)
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Page Margins (mm):
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Doctor's Signature & Seal
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Upload Images (Top: FOL 1–3 | Right column: FOL 4–6)
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FIBER OPTIC LARYNGOSCOPY (FOL) REPORT
Patient Name:
Patient ID:
Age:Y
Date of Birth:
Gender:
Address:
Mobile Number:
Referred by:
FOL 1
FOL 1
FOL 2
FOL 2
FOL 3
FOL 3
NASAL CAVITY / ROUTE:
NASOPHARYNX:
OROPHARYNX / BASE OF TONGUE / VALLECULA:
LARYNX (SUPRAGLOTTIC):
VOCAL CORDS (Appearance & Mobility):
SUBGLOTTIC / TRACHEAL INLET:
HYPOPHARYNX / PYRIFORM FOSSAE / POSTCRICOID:
DX:
Notes:
FOL 4
FOL 4
FOL 5
FOL 5
FOL 6
FOL 6
Doctor's Signature & Seal:
signature
Date:
Developed and designed by MD OMAR FARUK Developed and designed by MD OMAR FARUK [www.advancedhearingbd.com]