The image displays a printed document with various fields filled out in handwriting. The visible text includes names and numbers, which might be related to patient information given the context. The document has lines and sections for filling out details such as name, date of birth, address, diagnosis, and other personal information. There is also an area where medical professionals or staff can write additional notes or remarks regarding the patient's case. The document appears to be a form used in healthcare settings, possibly for tracking patients or updating medical records.