Republic of the Philippines

Center for Health Development No. 2

REGION II TRAUMA AND MEDICAL CENTER

Date: ___________________
MEDICO LEGAL FORM

NAME OF PATIENT: __________________________________________________________________ Age/Sex: _________________

(Last Name) (First Name) (Middle Name)
Address: _________________________________________________________________________ Tel/CP#: _________________________

Birth date: _________________ Religion: ________________ Nationality: ___________ Civil Status: Ch ( ) S() M() W ( ) Sep
()

Arrival Time: __________________ Brought by ( ) Self ( ) Police ( ) Relative ( ) others:

____________________

HISTORY:

Nature of Incident: _________________________________________________________________________________________________

Date of Incident: ___________________________________________________________________________________________________

Time of Incident: __________________________________________________________________________________________________

Place of Incident: __________________________________________________________________________________________________

DIAGNOSIS/DESCRIPTION OF INJURIES: __________________________________________________________________________

_________________________________________________________________________________________________________________

DISPOSITION: ___________________________________________________________________________________________________

( ) Admitted ( ) Treated & Discharged ( ) Expired

_________________________ ________________________________________
Nurse on Duty Attending Physician

FM-PS07-SU07-02
Brgy. Magsaysay, Bayombong, Nueva Vizcaya 3700 / Tel. Nos. (078) 805-3561-64 / Telefax No. (078) 805-3560/E-mail: v eteransregionalhospital@yahoo.com.ph