PATIENT’S RECORD

Case No. _________

Dr. _____________________________ Room No. ______

Name: Date Admitted: Time: AM/PM

Address: Tel. No.
Age: Sex: Civil Status: Nationality:
Date of Birth: Place of birth:
Religion: Occupation:
In case of emergency notify:
Address:
Name of nearest relative:
Address: Tel. No:
Condition on arrival: Brought by:
Admitted by: Discharged by:

Final Diagnosis:

Operation of Treatment:

Discharge on Time AM/PM Discharge by

Condition on discharge: ( ) Improved ( ) Unimproved ( ) Stable ( ) HAMA ( ) Died ( ) Others

Remarks:
( ) Private Patient
( ) Walk-in Case
( ) Medico-Legal Case
( ) PHIC , MD
( ) HMO Signature of Physician
( ) Senior Citizen ID No.
( ) Service Patient