Fill Report (One Page) — v9.9.2

Institute Header
PNG/JPG
Report Text
140px
100%
160px
100%
Page Margins (mm):
6mm
10mm
8mm
10mm
on print
Doctor's Signature & Seal
90%
10px
4px
Upload Images (Top: FOL 1–3 | Right column: FOL 4–6) Top row shows FOL 1–3; Right column shows FOL 4–6.
Footer (screen & print)
Helper
Institute / Clinic Name
Address line, city, country
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]