A&B Medical Hospital

Sanggali, Zamboanga City, Philippines

Telephone No.: 975–8782

PATIENT INFORMATION
Date:
Patient Name: _________________________________ Date of Birth_____/____/_____
LN FN MN Month Day Year

Address: ________________________________________________________________
Street City State Zip Code

Telephone Number: ___________________ Cellphone Number:__________________

Social Security Number:_________________ Sex: __Female __Male
Employer:_______________________ Work Phone Number:_______________________
Marital Status: __Single __Married __Divorced __Widowed
If married, spouse’s name: __________________________________
Spouse’s employer:________________________________________
Emergency Contact:_________________________ Relationship:_________________
Cellphone Number:_____________________
CHIEF COMPLAINT:________________________________________________________
________________________________________________________________________
Allergies
Drugs: Reaction:

Environment: Reaction:

Food: Reaction

INSURANCE INFORMATION

Primary Insurance Secondary Insurance

Subscriber ________________ Subscriber ________________
Policy Number ________________ Policy Number ________________
Group Number ________________ Group Number ________________
Insured’s DOB ________________ Insured’s DOB ________________
PHYSICIAN(S) INFORMATION

Referring Physician: ____________________________ Phone Number:_________________

Primary Care Physician: _________________________ Phone Number:_________________
Other Physicians involved in your care: __________________________________________
A&B Medical Hospital
Sanggali, Zamboanga City, Philippines
Telephone No.: 975-8782

INTAKE – OUTPUT CHART

Name Birthday
Date Patient No.
TIME INTAKE (ml)
MORNING Method Site
SHIFT
Additions Amount
Type of Fluid
6:00am per bag Put up Gone in

2:00pm Remainder
Total at the end of the shift
OUTPUT (ml)

TIME Drains
Urine N/G Aspirate Stoma Stool B.O
Etc.

6:00am

2:00pm
 A&B Medical Hospital
Sanggali, Zamboanga City, Philippines
Telephone No.: 975-8782
PHYSICAL EXAMINATION
If abnormal, can it
Signs,
List deviation from normal (and relevant baseline be caused by
Symptoms,
values) patient’s
Lab values
medications?
Date
VITAL SIGNS:
Temp
BP
HR
RR
CNS/
NEUROLOGIC
Confusion
Drowsiness
Dizziness
Fatigue
Numbness
Tingling
EENT
Voice change
Swallowing problem
Taste change

CVD
T.cholesterol
LDL / HDL
CO
SOB
Edema
Palpitation

PULMONARY
SOB
Wheezing
Coughing
Phlegm/Blood
Peak Flow
FLUID &
ELECTROLYTE
Na+
K+
Ca
Cl-
HCO3
Mg2+
 If abnormal, can it
Signs, Symptoms,
List deviation from normal (and relevant be caused by
Lab values
baseline values) patient’s
medications?
Date
RENAL
Se. Cr.
CrCl

LIVER
AST
ALT
Albumin
Bruising
Bleeding

GI

GU/REPRODUCTION

ENDOCRINE
Se. Glucose
HgA1C
TSH
T4

MSK

DERMATOLOGY

HEMATOLOGY
Hgb
Platelets
WBC
Neutrophils
INR
PTT
DRUG LEVELS
Digoxin
Theophylline
Lithium

CULTURES
A&B Medical Hospital
Sanggali, Zamboanga City, Philippines
Telephone No.: 975-8782

MEDICAL HISTORY
Patient Information
Patient’s Name: __________________________________ Age: _______
Gender: __ Female __Male Birthday: _______/______/____
Cellphone Number: _________________
Medical Information:
History of present illness

Past Medical History Family History

Social History:
Tobacco use: __ Yes __No Packs/day: ___________________________
__ Previous history of smoking
Alcohol use: __ Yes __No Drinks/week: _________________________
Caffeine use: __Yes __No Cups/day: ____________________________
Other recreational drug use: __Yes __No
List:

Immunization
Comments:
Medication List
Medication Reconciliation Completed: __Yes __No
Current Medication Indication Start Date Response
(including OTC and Herbals (safety and
effectiveness)

Antibiotic use in past 3 months