MODE OF  AMBULANCE PRIVATE VEHICLE OTHER TRIAGE

ARRIVAL  AMBULATORY WHEELCHAIR STRETCHER EMERGENT URGENT NON-URGENT

VITAL SIGNS REVIEW OF SYSTEMS

CONSTITUTIONAL
BP: CR: WT: FEVER MALAISE CHILLS POOR APPETITE
BODY PAINS WEIGHT LOSS
PALLOR RASHES BRUISING LACERATION
RR: TEMP: HT: HEMATOMA JAUNDICE OTHERS: ________________________

EENT
PAIN SCALE: O2 SAT: BMI: EYE PAIN EYE REDNESS BLURRED VISION EYE DISCHARGE
EAR PAIN HEARING LOSS RINGING IN EAR EAR DISCHARGE
NASAL PAIN EPISTAXIS CONGESTION NASAL DISCHARGE
TRAVEL HISTORY  YES NO
THROAT PAIN DYSPHAGIA ODYNOPHAGIA HALITOSIS
NECK PAIN NECK MASS NECK STIFFNESS NECK DEFORMITY
Places Travelled: ________________________________________________ OTHERS: _________________________

CHIEF COMPLAINT RESPIRATORY

COUGH DIFFICULTY OF BREATHING HEMOPTYSIS
 SHORTNESS OF BREATH OTHERS: ________________________

CARDIOVASCULAR
CHEST PAIN PALPITATION EASY FATIGABILITY ORTHOPNEA
PND VARICOSITIES EDEMA
HISTORY OF THE PRESENT ILLNESS FAINTING
 OTHERS: _________________________

GASTROINTESTINAL
 NAUSEA VOMITING DIARRHEA CONSTIPATION
HEMATEMESIS MELENA HEMATOCHEZIA ABDOMINAL PAIN
OTHERS: ________________________

GENITOURINARY / REPRODUCTIVE
DYSURIA NOCTURIA OLIGURIA PYURIA
HEMATURIA FREQUENCY URGENCY RETENTION
DYSPAREUNIA DISCHARGE OTHERS: _________________________

MUSCULOSKELETAL
MUSCLE / JOINT PAIN JOINT SWELLING JOINT STIFFNESS
BACK PAIN OTHERS: ________________________

ENDOCRINE
POLYDIPSIA POLYURIA EXCESSIVE THIRST  WEIGHT GAIN
HEAT INTOLERANCE COLD INTOLERANCE
EXCESSIVE SWEATING OTHERS: ________________________

NEURO / PSYCHIATRIC
HEADACHE DIZZINESS TINGLING NUMBNESS
SEIZURE MEMORY LOSS DYSARTHRIA DYSPHONIA
ANXIETY DEPRESSION OTHERS: ________________________

PAST MEDICAL HISTORY

CARDIAC DISEASE A-FIB ANGINA CHF
AMI
HYPERTENSION
ASTHMA
COPD EMPHYSEMA CHRONIC BRONCHITIS
DIABETES TYPE I TYPE 2
STROKE INFARCT HEMORRHAGIC TIA
CANCER
OTHERS
PREVIOUS SURGERIES / PROCEDURES

CURRENT MEDICATIONS

ALLERGIES
__________________________
Signature over Printed Name IMMUNIZATIONS
(RESIDENT ON DUTY)
License No.

Form No.:

Hospital No:

Case No:

Room No:

PATIENT ASSESSMENT FORM

PATIENT’S NAME: AGE: SEX:

ATTENDING PHYSICIAN: DATE:

 FAMILY HISTORY OB-GYNE HISTORY
OB SCORE: G P ( )

Menstrual History: Menarche Interval Duration

Operation:
REGULAR IRREGULAR

LMP EDC
PMP OTHERS:

AOG

PERSONAL / SOCIAL HISTORY

SMOKER
PACK YEARS: _
QUIT: YES NO

ALCOHOL INTAKE:
HEAVY OCCASIONAL
QUIT: YES NO

ILLICIT DRUG USE: ________________

QUIT: YES NO

GENERAL
APPEARANCE

SKIN

HEENT

HEART

CHEST / LUNGS

ABDOMEN
RECTUM / GENITALIA

EXTREMITIES

NEURO
ADMITTING DIAGNOSIS: