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Name: Medical Record #: Age/Sex: Civil Status: Address: Birth Place: Informant: Admitting Dx:

OPD Occupation: HMO: Birthday: Relationship: Final Dx:

IN-PATIENT Date Admitted: Date Discharge: Religion: Contact #:

Vital Signs: T: PR: Date/Time Chief Complaint

RR: Diagnosis

BP: WT: Home Meds

O2 Sat: Procedure/s Done

Date/Time

Chief Complaint

Diagnosis

Home Meds

Procedure/s Done

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