TEMPLATES (Patient's Profile, Intake&Output, Physical Exam, Medical History)
TEMPLATES (Patient's Profile, Intake&Output, Physical Exam, Medical History)
TEMPLATES (Patient's Profile, Intake&Output, Physical Exam, Medical History)
PATIENT INFORMATION
Date:
Patient Name: _________________________________ Date of Birth_____/____/_____
LN FN MN Month Day Year
Address: ________________________________________________________________
Street City State Zip Code
Environment: Reaction:
Food: Reaction
INSURANCE INFORMATION
2:00pm Remainder
Total at the end of the shift
OUTPUT (ml)
TIME Drains
Urine N/G Aspirate Stoma Stool B.O
Etc.
6:00am
2:00pm
A&B Medical Hospital
Sanggali, Zamboanga City, Philippines
Telephone No.: 975-8782
PHYSICAL EXAMINATION
If abnormal, can it
Signs,
List deviation from normal (and relevant baseline be caused by
Symptoms,
values) patient’s
Lab values
medications?
Date
VITAL SIGNS:
Temp
BP
HR
RR
CNS/
NEUROLOGIC
Confusion
Drowsiness
Dizziness
Fatigue
Numbness
Tingling
EENT
Voice change
Swallowing problem
Taste change
CVD
T.cholesterol
LDL / HDL
CO
SOB
Edema
Palpitation
PULMONARY
SOB
Wheezing
Coughing
Phlegm/Blood
Peak Flow
FLUID &
ELECTROLYTE
Na+
K+
Ca
Cl-
HCO3
Mg2+
If abnormal, can it
Signs, Symptoms,
List deviation from normal (and relevant be caused by
Lab values
baseline values) patient’s
medications?
Date
RENAL
Se. Cr.
CrCl
LIVER
AST
ALT
Albumin
Bruising
Bleeding
GI
GU/REPRODUCTION
ENDOCRINE
Se. Glucose
HgA1C
TSH
T4
MSK
DERMATOLOGY
HEMATOLOGY
Hgb
Platelets
WBC
Neutrophils
INR
PTT
DRUG LEVELS
Digoxin
Theophylline
Lithium
CULTURES
A&B Medical Hospital
Sanggali, Zamboanga City, Philippines
Telephone No.: 975-8782
MEDICAL HISTORY
Patient Information
Patient’s Name: __________________________________ Age: _______
Gender: __ Female __Male Birthday: _______/______/____
Cellphone Number: _________________
Medical Information:
History of present illness
Social History:
Tobacco use: __ Yes __No Packs/day: ___________________________
__ Previous history of smoking
Alcohol use: __ Yes __No Drinks/week: _________________________
Caffeine use: __Yes __No Cups/day: ____________________________
Other recreational drug use: __Yes __No
List:
Immunization
Comments:
Medication List
Medication Reconciliation Completed: __Yes __No
Current Medication Indication Start Date Response
(including OTC and Herbals (safety and
effectiveness)