ADMISSION FORM TO HOSPITAL

I.
Identity Information
Medical Number :
Name:
Date of Birth :
Address :
Occupation :
Last Education :
Medic Diagnose :
Parents name : Father :
II.
Health History
Pulse
Blood pressure:
Present Health Story

Previous / Last Health Story

Family Health Story

III.

Habbits
Eat :
Drink :
Sleep :
Elimination :

Date of Admission :
Age:

Time :
Sex:

Religion :
Phone Number :
Mother :
Respiration :

Temperature:

Question
1. Name :
What is your name ?
What is her/his name?
What is your fathers/your mothers name?
What is your friends name?
2. Date of birth :
When were you born ?
When was your sister/brother born ?
When was your mother/father born ?
What date your fathers/ mothers were born?
How old are you?
How old is your mother / father ?
What is your age ?
Where you were born?

3. Address
Where do you live?
Where do you come from?
What is your address ?
4. Occupation
May I know you work ?
Where do you work ?
What are you ?
5. Religion
What is your religion ?
6. Education

 What your last education

7. Parents name
What is your mothers name?
What is your father name?

8. Phone Number
Do you heve phone number ?
May I know your phone number ?

Health Story
Present Health Story
Question

What is your Problem ?

What is your complaint now?
Whats wrong wit you?
What do you feel now?
How about your condition?
Whats brought you here ?

Previous/last health story

How long have your been feeling unwell?
What medicine did you take ?
Have you taken any medicine ?
Have you ever received any treatment before ?
Family health story
Whethewer your family is also suffering from the same desease ?

9. Habbits