VITAL INFORMATION

A. PATIENT’S DATA

Patient’s Name: Mr. JP

Address: Barrio 1, Koronadal City, South Cotabato

Age: 13 years old

Sex: Male

Tribe: Ilonggo

Nationality: Filipino

Religion: Iglesia ni Kristo

Date of Birth: May 12, 1997

Place of Birth: Barrio 1, Koronadal City, South Cotabato

Civil Status: Single

Occupation: Student

Educational Attainment: First year Highschool

Name of Hospital: Allah Valley Medical Specialist Center Incorporated

Date and time of admission: November 8, 2010 at 4:09 pm

Attending Physician: Dr. Anthony Pascua

Chief complaint: Swelling of left leg

Admitting diagnosis: Fracture close, supracondylar femur left

Reason for Admission: For surgery

Date and time of operation: November 9, 2010 at 9:00 am

Surgeon: Dr. Anthony Pascua

Anesthesiologist: Dr Jose Ferrante Solano

Time started: 10:00 am

Time ended: 11: 15 am

Operation Done: Open Reduction buttress plating supracondylar femur left with

intercondylar extension

Pre-operative diagnosis: Supracondylar femur fracture left

Post-operatve diagnosis: Fracture close, supracondylar femur left with intercondylar extension

Usual source of healthcare: Hospital and Health Center

Health care financing: None

Source of income: Salary of patient’s father

PARENT’S DATA

Mother’s Name: Mrs. A Father’s Name: Mr. B

Age: 43 Age: 44

Occupation: House keeper Occupation: Pop rice maker

PATIENT’S SIBLINGS

Name Age Occupation Educational Attainment

1. Ms. C housekeeper Highschool graduate

2. Ms. D none Highschool graduate
3. Ms. E none Fourth year highschool
4. Mr. F 17 years old Student Fourth year highschool
5. Mr. JP 13 years old Student First year highschool

Income:
E. EFFECTS TO SELF AND FAMILY

F. EXPECTATION TO SELF AND FAMILY