Republic of the Philippines

PROVINCIAL HEALTH OFFICE

ILOCOS SUR PROVINCIAL HOSPITAL – GABRIELA SILANG

Vigan City

RADIOLOGY REQUEST FORM

X- RAY ULTRASOUND CT-SCAN MRI PORTABLE

DATE: 10/26/2021 HOSPITAL CASE NO. MIS-004-0 FILM NUMBER .

WARD: medical . PHILHEALTH CLASSIFICATION: self-employed .

NAME OF PATIENT:
.
Foronda Eduardo Facundo________
FAMILY NAME GIVEN NAME MIDDLE NAME
ADDRESS: Maas-asin, Magsingal, Ilocos Sur AGE: 54 y/o SEX: M CIVIL STATUS: Married_
DATE OF BIRTH: October 23, 1967 .

Pertinent History and Clinical Findings: Patient has a history of hypertension, and is alcoholic. To
consider liver damage due to alcoholism possible for liver transplant
.

Previous X-RAY, CT SCAN, MRI, ULTRASOUND in ISPH-GS

.
WARD: YES DATE:

CLINICAL DIAGNOSIS: Liver Cirrhosis .

EXAMINATION DESIRED: CT- SCAN .

Marie Irene G. Andrada, RRT 10/26/2021 Bernardo Joel Ragasa, MD

RADIOLOGIC TECHNOLOGY/ DATE PERFORMED Requesting Physician
RADIOLOGIST (signature Over Printed Name)
RAD-012-0