PATIENT ADMISSION FORM

PERSONAL DETAILS Name : Next of Kin : GeorgeJakes Address : Name of GP : Dr Andrea Patients understanding of admission : Investigation of chest pain MEDI AL IN!ORMASION Re"e#ant medi$a" %istor& : Varicose veins Pains in chest increasing over past three months A""ergies : None 'o(e"s : Suffers from constipation, takes Ex !ax )rinar& : "rinates a #ot, especia##$ at night interferes %ith s#eep *!ema"e +atient, Menstruation : periods stopped &'( $ears ago -earing : )k .ision : *ear g#asses Ora" : *ear dentures +upper and #o%er

Referral letter someone to a hospital. Here is a sample of a referral letter) write by dr. Mary Chapman to Dr. Scott. The nurse asks the patient : Do you brin referral letter with you! LINI AL DETAILS Dear Dr.Scott " would be rateful for your opinion and ad#ice with re ard to $%ame ) &R''%( )eter *R&'%T )lease indicate "n the bo+ , brief outline of history( symptoms and si ns and present therapy is i#en below : This -./ year/ old salesman had a se#ere attack of central chest paint si+ month a o which lasted 01 mins and was relie#ed by rest. This has recurred se#eral times after e+ertion. His father died a ed 23 of a coronary thrombosis. )hysical e+amination was normal and refer him to you for further assessment in #iew of his a e. Dia nosis : an ina Thank you for seein him. 4our sincerely. "t transport re5uired please state : Stretcher6sittin case. Sittin case 7 two man lift 4'S %8 Si nature ,ar$ -hapman

St/ 0ames Medi1a enter Admission ard S*R' %,M' $"% :;8C< ;'TT'R) 9hat=s your name! How do you spell it please! %ame please> ,DDR'SS @T';')H8%' %8. 9here do you li#e! ,re you on the phone! C"A"; ST,T' Married Sin le 9idowed 8ther ,re you married! R';'&"8% 9hat=s your reli ion! %ote: "n some states( it=s no appropriate to ask this 5uestion. "t=s necessary to follow the culture. %,M' @ ,DDR'SS 8? &.)C) 9ho=s your family doctor His ,ddress! 9hat=s his address!

Hospital. Re . %o : 9ard6Dept. ?"RST %,M' $S) 9hat=s your first name! $your Christian names) How do you spell it ! D,T' 8? :"RTH 9hen were you born! 4our date of birth please> 8CC*),T"8% $in this case of child( father=s occupation) 9hat=s your occupation 9hat=s his father=s occupation %,M' @ ,DDR'SS %'BT 8? <"% 9ho=s your nearest relati#e! 4our ne+t of kin Do you li#e at the same address T';')H8%' %8. $"f no phone( i#e a number where messa es may be sent. ,dd messa e only). 9ho can " i#e messa e! ,ny contact person in emer ency case!