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    2 views1 page

    Patient Chart Med Car

    Uploaded by

    Luigi Lazarte

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 1

    MEDISINA SA LAHAT: Medical Caravan

    MARTIN LEACHON KURT CASTELO NOCUM


    Modernong Kabuhayan para sa Maunlad Good Health para sa Good Life
    na Lungsod

    ALLERGY TO: ________________________

    Patient No. ___________________________________


    __

    INFORMANT: DATA 1
    DATE :

       
    PATIENT’S NAME AGE SEX BIRTHDAY

      
    MOTHER’S NAME FATHER’S AME WEIGHT TEMP. CONTACT NUMBER


    ADDRESS

    BIRTH HISTORY ILLNESS HISTORY


    _______ TERM ________ WEEKS ALLERGIES : ______________
    _______ PREMATURE ________ WEEKS CHICKEN POX : ______________
    _______ MONTHS ________ WEEKS DIPTHERIA : ______________
    TYPE OF DELIVERY : ___________________ MEASLES : ______________
    CONDITION AT BIRTH: ___________________ RUBELLA : ______________
    WEIGHT : _________ LENGTH : ____________ MUMPS : ______________
    BREASTFED : _________________________ PNEUMONIA : _____________
    BOTTLEFED : _________________________ PRIMARY COMPLEX : ______________
    FORMULA : _________________________ HIPATITIS : ______________
    VITAMINS : _________________________ TONSILLITIS : ______________
    FOLLOW ON : _________________________ INJURIES : ______________
    OTHERS : _________________________ OPERATIONS : ______________

    IMMUNIZATION HISTORY
    1ST REACTION 2ND REACTION 3RD REACTION
    BCG __________: __________ _ : __________ : __________ : __________ : ____________
    DPT __________: __________ _ : __________ : __________ : __________ : ____________
    BOOSTERS __________: __________ _ : __________ : __________ : __________ : ____________
    POLIO __________: __________ _ : __________ : __________ : __________ : ____________
    BOOSTERS __________: __________ _ : __________ : __________ : __________ : ____________
    MEASLES __________: __________ _ : __________ : __________ : __________ : ____________
    SMALLPOX __________: __________ _ : __________ : __________ : __________ : ____________
    CHOLERA __________: __________ _ : __________ : __________ : __________ : ____________
    TYPHOID __________: __________ _ : __________ : __________ : __________ : ____________
    TETANUS __________: __________ _ : __________ : __________ : __________ : ____________
    GERMAN MEASLES __________: __________ _ : __________ : __________ : __________ : ____________
    INFLUENZA __________: __________ _ : __________ : __________ : __________ : ____________
    HEPATITIS __________: __________ _ : __________ : __________ : __________ : ____________
    MUMPS __________: __________ _ : __________ : __________ : __________ : ____________
    TUBERCULIN __________: __________ _ : __________ : __________ : __________ : ____________

    7
    FAMILY DISEASES:
    _________ALLERGY _________RENAL ___________BLOOD DIS.
    _________CARDIAC _________DIABETES ___________OTHERS
    _________T.B. _________HPN
    _________CANCER _________HEPATITIS
    File/Data1.ed

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