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  • DC: Home/Transfer DC: Home/Transfer

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    Sammy Levuong
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    This document appears to be a medical intake form containing sections for patient information including name, height, room number, weight, blood sugar, admitting physician, vital signs, allergies, chief complaint, medical history, surgeries, habits, labs/diagnostics, medications given, discharge condition and destination, and fields for the evaluating room and nurse. Medical history categories include common conditions such as diabetes, hypertension, asthma, and mental health diagnoses.

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    er brain for nursing school

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    ER Brain

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    This document appears to be a medical intake form containing sections for patient information including name, height, room number, weight, blood sugar, admitting physician, vital signs, allergies, chief complaint, medical history, surgeries, habits, labs/diagnostics, medications given, discharge condition and destination, and fields for the evaluating room and nurse. Medical history categories include common conditions such as diabetes, hypertension, asthma, and mental health diagnoses.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as pdf or txt
    14 views1 page

    DC: Home/Transfer DC: Home/Transfer

    Uploaded by

    Sammy Levuong
    This document appears to be a medical intake form containing sections for patient information including name, height, room number, weight, blood sugar, admitting physician, vital signs, allergies, chief complaint, medical history, surgeries, habits, labs/diagnostics, medications given, discharge condition and destination, and fields for the evaluating room and nurse. Medical history categories include common conditions such as diabetes, hypertension, asthma, and mental health diagnoses.

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    © All Rights Reserved
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    of 1

    Name: Ht: RM # Name: Ht: RM # Admit MD: Wt: BS: Admit MD: Wt: BS: DX: IV: ​□ Assessment

    ​DX: IV: ​□ Assessment


    Allergies: ​□Home □BLS/ALS □Squad ____ ​Allergies: ​□Home □BLS/ALS □Squad ___ ​CC: VS:​@ ​CC: VS:​@
    T: T: BP: BP: P: P:
    Med. Hx: ​□ DM I/II □ ESRD □ CKD □ Renal Failure □ Hypothyroid/Hyperthyroid
    □ CAD □ CVA/Stroke □ HTN □ High Chol. □ CHF □ Arrythmia __ ____
    □ Ashtma □ Bronchitis □ Pneumonia □ COPD □ Hep.A/B/C □ HIV/AIDS
    □ Osteoporosis □ Arthritis □ Seizures □ Gastritis □ Other:____ _____
    R: O2: Med. Hx: R:
    O2:
    □ Depression □ Bipolar □ Schizonprenia □ Anxiety □ CA ______ _____
    Pain: Pain: Surgeries: VS:​@ ​Surgeries: VS:​@
    T: T: BP: BP: Caf./Tob./ETOH/Drugs: P: Caf./Tob./ETOH/Drugs: P: R: R: Labs/Dx: O2: Labs/Dx: O2:
    Pain: Pain:
    Medication Given: D​ C: Home/Transfer ​Medication Given: D​ C: Home/Transfer
    ER: ER:
    RM: RM:
    RN: RN:

    Name: Ht: RM # Name: Ht: RM #


    Wt: BS: Wt: BS: Admit MD: IV: ​□ Assessment ​Admit MD: IV: ​□ Assessment ​DX: ​□Home □BLS/ALS □Squad ____ ​DX: ​□Home □BLS/ALS
    □Squad ____ ​Allergies: Allergies: CC: VS:​@ ​CC: VS:​@

    T: T: BP: BP: Med. Hx: R​ M: ​P: Med. Hx: P: R: R: O2: O2: Surgeries: Pain: Surgeries: Pain:
    VS:​@ ​VS:​@ ​T: T: Caf./Tob./ETOH/Drugs: BP: Caf./Tob./ETOH/Drugs: BP:
    P: P: Labs/Dx: R: Labs/Dx: R:
    O2: O2: Pain: Pain:
    Medication Given: D​ C: Home/Transfer ​Medication Given: D​ C: Home/Transfer
    ER: ER:
    RM: RM:
    RN: RN:
    □ DM I/II □ ESRD □ CKD □ Renal Failure □ Hypothyroid/Hyperthyroid
    □ CAD □ CVA/Stroke □ HTN □ High Chol. □ CHF □ Arrythmia ___ ____
    □ Ashtma □ Bronchitis □ Pneumonia □ COPD □ Hep.A/B/C □ HIV/AIDS
    □ Osteoporosis □ Arthritis □ Seizures □ Gastritis □ Other:____ _____
    □ Depression □ Bipolar □ Schizonprenia □ Anxiety □ CA ______ _____
    □ DM I/II □ ESRD □ CKD □ Renal Failure □ Hypothyroid/Hyperthyroid
    □ CAD □ CVA/Stroke □ HTN □ High Chol. □ CHF □ Arrythmia __ ____
    □ Ashtma □ Bronchitis □ Pneumonia □ COPD □ Hep.A/B/C □ HIV/AIDS
    □ Osteoporosis □ Arthritis □ Seizures □ Gastritis □ Other:____ _____
    □ Depression □ Bipolar □ Schizonprenia □ Anxiety □ CA ______ _____
    □ DM I/II □ ESRD □ CKD □ Renal Failure □ Hypothyroid/Hyperthyroid
    □ CAD □ CVA/Stroke □ HTN □ High Chol. □ CHF □ Arrythmia ___ ____
    □ Ashtma □ Bronchitis □ Pneumonia □ COPD □ Hep.A/B/C □ HIV/AIDS
    □ Osteoporosis □ Arthritis □ Seizures □ Gastritis □ Other:____ _____
    □ Depression □ Bipolar □ Schizonprenia □ Anxiety □ CA ______ _____

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