Date Complaint (S) /vital Signs Diagnosis/Treatment: Tetanus Toxoid Date Given

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TABUK CITY, KALINGA

CITY HEALTH OFFICE 1


CLINICAL HEALTH RECORD

COMPLETE NAME: _____________________________________________ BIRTHDATE: _____________AGE______SEX: _____


(LAST NAME) (FIRST NAME) (MIDDLE NAME)
COMPLETE ADDRESS: __________________________________________ OCCUPATION: ______________________________
(PUROK, BARANGAY)
PHIC/PANT #: _______________________________________ CP #: ______________________________________________

NAME OF PARTNER: _____________________________________________ BIRTHDATE: ______________AGE____________

LMP: _________________________ EDC: ___________________________OB SCORE: G_____P_____ (_________)

TETANUS TOXOID
DATE GIVEN

DATE COMPLAINT(S)/VITAL SIGNS DIAGNOSIS/TREATMENT

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