Surname

First Name M.I. Age Sex Civil Status Admission No. Attending Physician

Diagnosis Room/Ward

TPR GRAPHIC SHEET

Temp. Pulse Date Date Date Date Date

12 4 8 12 4 8 12 4 8 12 4 8 12 4 8 12 4 8 12 4 8 12 4 8 12 4 8 12 4 8
41 100

90
40

80
39

70
38

37 80

70
36

60
35

50

40

Respiration

Blood
Pressure

No. of
times/shift urine stool urine stool urine stool urine stool urine stool
Weight