Name of student: Sobrepena, Jovi

Surname, Firstname, M.I.

Year&Sec: Date:
Area:
Days: Time:

Name

Address:
Age: Birthday Sex: Religion:
m d year
Room No.:
Bed No.: Attending physician
Date of admission Time of admission

VITAL SIGN FREQUENCY

10:00 AM 2:00 PM 6:00 PM 10:00 PM 2:00 AM 5:59 AM
BP
PR
RR
TEMP
CR
O2 SAT.
others:
GCS:
Weight(Kg) Height(m) BMI:

Family History
YES NO REMARKS

Allergy

Arthritis

Bronchial Asthma

Palmonary Tubercolosis

Hypertension

Thyroid Disease

Nuerological Disorders

Diabetes Mellitus

Heart Disease

Gastrointestinal Disease

Kidney Disease

Blood Disorder

Psychiatric Illness

Others:
 Name of student: Sobrepena, Jovi
Surname, Firstname, M.I.
Year&Sec: Date:
Area:
Days: Time:

Name

Address:
Age: Birthday Sex: Religion:
m d year
Room No.:
Bed No.: Attending physician
Date of admission Time of admission

VITAL SIGN FREQUENCY

10:00 AM 2:00 PM 6:00 PM 10:00 PM 2:00 AM 5:59 AM
BP
PR
RR
TEMP
CR
O2 SAT.
others:
GCS:
Weight(Kg) Height(m) BMI:
III. IV FLUIDS
Type: Time received:
Level received: (ml) Regulation: (gtts/mcgtts/min)
Duration: (Hrs.) IVF To Follow:

macroset microset
volume: volume:
regulation: regulation:
duration: duration:
volume per hour: volume per hour:

Received:
Infused:
Endorsed:
IV. INTAKE AND OUTPUT (I&O)
INTAKE OUTPUT
TIME ORAL/NGT IVF URINE STOOL

TOTAL
GRAND TOTAL
Family History
YES NO REMARKS

Allergy

Arthritis

Bronchial Asthma

Palmonary Tubercolosis

Hypertension

Thyroid Disease
Nuerological Disorders

Diabetes Mellitus
Heart Disease

Gastrointestinal Disease

Kidney Disease