GENA FAMILY PLANNING AND MATERNITY CLINIC

#15 Don Julian St. Doa Pilar Village, Sasa, Davao City
ADMISSION FORM
Case No.:__________________
Date Admitted:_______________ Time: ______________
Date Discharged:______________Time: _______________
PATIENTS INFORMATION
Last Name
First Name
Religion

Occupation

Philhealth Member:
YES [ ]
NO [ ]
Middle Name

Birthday

Civil Status: S [ ] M
[ ]
Maiden Name:

Age

Address:

Contact No.:

HUSBANDS INFORMATION
Last Name
First Name
Religion

Occupation

Middle Name

Birthday

Civil Status:

Age

Date and Place of Marriage

Contact No.:

PREGNANCY DETAILS
Last Menstrual
Expected Date of
Period
Delivery

AOG

OB Score

Menarche

G__P__A (_________)

Chief Complain:
Admitting Diagnosis:
Final Diagnosis:
DELIVERY CHART
Date & Time of Delivery:
Date: _____________
Time: _____________
Sex: ______________

Weight:_______________
Birth Outcome:______________
Apgar Score:________________

Maternal Outcome:______________
AOG By LMP:_________________
Presentation:___________________

PAGTUGOT SA ADMISYON UG PAG-EKSAMIN

Ako, ________________________ nga gidala sa GENA FAMILY PLANNING AND MATERNITY CLINIC,
pinaagi niining kasulatan nagahatag saakong pagtugot sa admisyon, eksaminasyon, ug pagpatamnal sa nahisgutan
nga pasyente, sumala sa katakus ug pagdumala sa mga personnel sa GENA FAMILY PLANNING AND
MATERNITY CLINIC. Dugang pa niini, ang GENA FAMILY PLANNING AND MATERNITY CLINIC ug iyang
staff gawasnon sa tanang obligasyon o tulubagon alang sa bisan unsang mahitabo nga nagresulta gikan sa gihimong
serbisyo medikal alang sa pasyente sulod sa GENA FAMILY PLANNING AND MATERNITY CLINIC.
Dugang pa niini akong nabasa ug hugot na nasabtan ang tanang nakasulat ug wala ko gipugos o gigamitan og
puwersa aron ko mupirma.
_______________________________
Signature over printed name (Witness)

________________________________
Signature over printed name (Patient)
DISCHARGE CONSENT
I certify that I was discharged together with my baby in good condition
Date and Time of Discharge: _______________________
___________________________
Vital Signs: BP:_______ WT:________ RR:________ Temp.: _________
Signature over Printed Name