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CLASSIFICATION:
HOUSE CASE
PRIVATE CASE
ATTENDING PHYSICIAN:________________
DATE:_____________________
TIME:_____________________
FIRST NAME
ADDRESS
DATE OF BIRTH
BED NO.
GENDER
CIVIL STATUS:
TEL. NUMBER
AGE
RELIGION:
MIDDLE NAME
OCCUPATION
MOBILE NUMBER
EMPLOYER NAME/ADDRESS:
NEXT OF KIN:
ADDRESS
TEL. NUMBER
MOBILE NUMBER
TEL. NUMBER
MOBILE NUMBER
CONSENT TO TREATMENT: The UNDERSIGNED grants authority to THE PREMIER MEDICAL CENTER and its staff
to perform those procedure and treatments deemed necessary for the patient whose name appears above.
________________________________
Patients/Representatives Signature Over
Printed Name
CHIEF COMPLAINT:
BP
PR
RR
TEMP
WEIGHT
HEIGHT
PHYSICAL EXAMINATION
HEENT
NECK
LUNGS/CHEST
ABDOMEN
EXTREMITIES
INTEGUMENTARY
GCS
EYE OPENING
VERBAL RESPONSE
MOTOR RESPONSE
TOTAL
4
5
6
15
DIAGNOSIS:
PHYSICIANS ORDERS:
TIME
DISCHARGE ORDERS
DISPOSITION
DATE
DISCHARGED
TIME
DAMA
ADMITTED
TRANSFERRED
TO HOSPITAL
_______________
EXPIRED
____________________________________M.D.
____________________________R.N.
DOC NSD - 0002