RAJASTHAN INSTITUTE OF NURSING-ABU ROAD (SIROHI) (RECOGNISED BY: RNC, INC & RAJ GOVT)

S.NO NAME DATE OF ADMISSION

: : : SEX :

DATE OF BIRTH : .

PROGRAMME OF STUDY: PERMANENT ADDRESS : .

I.FAMILY HEALTH RECORD FAMILY MEMBERS AGE(YEAR) DISEASE IN THE FAMILY (DIABETES, HYPERTENSION, HEART DISEASE, MENTAL DISEASE, EPILEPSY, TB, LEPROSY ETC.) IF ANY ONE DATE : CAUSE :

FATHER MOTHER SIBLING(SEPCIFY BROTHER OR SISTER)

II. PERSONAL HEALTH RECORD 1. ILLNESS DURING CHILDHOOD (0-12 YRS.) 5. USE OF SPECTACLES (SPECIFY EYE DEFECT &THE AGE WHEN STARTED 2. SUBSEQUENT ILLNESS (AFTER 12 YRS.) 3. PHYSICAL DISABILITY: CAUSE 4. ALLERGY TYPE OF REACTION CAUSE OF ALLERGY (DRUG, FOOD, COSMETICS, DUST-SPECIFY) 6. IF FEMALE-MENSTRUAL PERIODS A. B. C. D.

III. IMMUNIZATION IMMUNIZATION BCG HEPATITISS B TET. TOXOID CHICKEN POX OTHERS I DOSE II DOSE III DOSE BOOSTER DOSE

IV. ANNUAL MEDICAL EXAMINATION I YEAR HEIGHT &WEIGHT NURITTIONAL EYE ENT TEETH THYROID LYMPH NODES CARDIO VASCULAR SYSTEM RESPIRATORY SYSTEM GASTRO INTESTINAL SYSTEM URINARY SYSTEM SKELETAL SYSTEM NERVOUS SYSTEM SKIN PULSE RATE BLOOD PRESSURE POSTURE OTHERS REMARKS DOCTOR SIGNATURE II YEAR III YEAR INTERSHIP

V. LABORATORY FINDINGS (DATE & RESULT) BLOOD URINE STOOL X-RAY

VI. DATE & ANY SIGNIFICANT REMARKS, RECOMMENDATION

VII. MONTHLY WEIGHT RECORDS JULY AUG SEP OCT NOV DEC

YEAR JAN FEB MARCH APRIL MAY JUN

VIII. SUMMARY OF OUTPATIENT TREATMENT DATE TREATMENT & REMARKS DATE TREATMENT & REMARKS

SIGNATURE OF STUDENT

PRINCIPAL