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Last Name First Name (Suffix, if any) Middle Name Health Record #

Age/Sex Date of Birth (mm/dd/yy) Ward Rm/Bed

TPR SHEET
Days of Month

No. of Days in Hosp.

Height/Weight

Res Puls Te
pira e mpe
tion ratu
re

42
42

180 41

40

160

38
39

140 37

36

120 35

100

60

50 80

40

30 60

20

10
7-3
URINE
3-11
TIMES OR CC
11-7

STOOL 7-3

3-11
NOS
11-7

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