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PATIENT RECORD

Name of Hospital Hospital Reg. No:

Admission Card Ward/ Dept.:

SURNAME (IN BLOCK LETTERS) ……………………………………………………..

FIRST NAME (S) ………………………………………………………………………….

GENDER M F DOB …………………………………………………

PLACE OF BIRTH …………………………………………………………………………

ADDRESS & TELEPHONE NO. …………………………………………………………..

…………………………………………………………………………………………………

MARITAL STATUS …………………………………………………………………………

OCCUPATION ………………………….......RELIGION …………………………………

NAME, ADDRESS & CONTACT NO. OF NEXT OF KIN ……………………………….

………………………………………………………………………………………………….

………………………………………………………………………………………………….

SMOKING INTAKE …………………………………………………………………………

ALCOHOL INTAKE …………………………………………………………………………

ALLERGIES ………………………………………………………………………………….

REASON FOR ADMISSION ………………………………………………………………..

………………………………………………………………………………………………….

MIDICAL HISTORY …………………………………………………………………………

FAMILY HISTORY …….mental illness ……TB …HIV/ AIDS ……DM

VITAL SIGNS T=……….. P=……………. R=……………. BP=………………..