MARY JOHNSTON HOSPITAL

1221 Juan Nolasco Street, Tondo, Manila 1012

Tel Nos. (632) 245-4021 to 25 Fax No. (632) 245-4487
PhilHealth Accredited

Hospital Case No. Last Name: Date Of Birth:

Date of Admission: First Name: Age/ Gender:
Attending Physician: Middle Name: Civil status:

Chief Complaint:

History of Present Illness:……………………………………………………………………………………………………………………………………………………………..

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Past Medical History: Family Medical History: Personal & Social History:
( ) HPN ( ) Heart Disease ( ) Asthma ( ) Hypertension ( ) Cancer ( ) Smoker
( ) Dm ( ) PTB ( ) Allergy ( ) DM ( ) Asthma ( ) Alcoholic Drinker
( ) UTI ( ) PTB ( ) Substance Abuse

Review Of Systems:
( ) Fever ( ) Headache ( ) Dizziness (- )SOB/DOB ( ) Cough ( ) Colds ( ) Chest Pain ( ) Orthopnea ( ) Easy Fatiguability
( ) Vomiting ( ) LBM ( ) Abdominal Pain (-) Dysuria ( ) Hematuria ( ) Melena ( ) Hematochezia
( ) Body Weakness ( ) Edema ( ) Weight Loss
Physical Examination: Medications on Board:
Vital signs: BP:________ HR:______ RR:________ Temp:______ ………………………………………………………………
General:………………………………………………………………………………………………………… ………………………………………………………………
Head and Neck:……………………………………………………………………………………………..
Chest:……………………………………………………………………………………………………………
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Cardio Vascular:……………………………………………………………………………………………. ………………………………………………………………
Abdomen:……………………………………………………………………………………………………… ………………………………………………………………
Extremeties:………………………………………………………………………………………………….. ………………………………………………………………
Laboratory & Diagnostics Examination: ………………………………………………………………
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(Course in the Ward)
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Final Diagnosis:

Consultant- In-Charge Resident-In-Charge Date Accomplished

-NOT VALID FOR MEDICOLEGAL PURPOSE-

rev04.28.2016mjhform