Professional Documents
Culture Documents
1 Patient Assessment Form.
1 Patient Assessment Form.
1 Patient Assessment Form.
EENT
PAIN SCALE: O2 SAT: BMI: EYE PAIN EYE REDNESS BLURRED VISION EYE DISCHARGE
EAR PAIN HEARING LOSS RINGING IN EAR EAR DISCHARGE
NASAL PAIN EPISTAXIS CONGESTION NASAL DISCHARGE
TRAVEL HISTORY YES NO
THROAT PAIN DYSPHAGIA ODYNOPHAGIA HALITOSIS
NECK PAIN NECK MASS NECK STIFFNESS NECK DEFORMITY
Places Travelled: ________________________________________________ OTHERS: _________________________
CARDIOVASCULAR
CHEST PAIN PALPITATION EASY FATIGABILITY ORTHOPNEA
PND VARICOSITIES EDEMA
HISTORY OF THE PRESENT ILLNESS FAINTING
OTHERS: _________________________
GASTROINTESTINAL
NAUSEA VOMITING DIARRHEA CONSTIPATION
HEMATEMESIS MELENA HEMATOCHEZIA ABDOMINAL PAIN
OTHERS: ________________________
GENITOURINARY / REPRODUCTIVE
DYSURIA NOCTURIA OLIGURIA PYURIA
HEMATURIA FREQUENCY URGENCY RETENTION
DYSPAREUNIA DISCHARGE OTHERS: _________________________
MUSCULOSKELETAL
MUSCLE / JOINT PAIN JOINT SWELLING JOINT STIFFNESS
BACK PAIN OTHERS: ________________________
ENDOCRINE
POLYDIPSIA POLYURIA EXCESSIVE THIRST WEIGHT GAIN
HEAT INTOLERANCE COLD INTOLERANCE
EXCESSIVE SWEATING OTHERS: ________________________
NEURO / PSYCHIATRIC
HEADACHE DIZZINESS TINGLING NUMBNESS
SEIZURE MEMORY LOSS DYSARTHRIA DYSPHONIA
ANXIETY DEPRESSION OTHERS: ________________________
CURRENT MEDICATIONS
ALLERGIES
__________________________
Signature over Printed Name IMMUNIZATIONS
(RESIDENT ON DUTY)
License No.
Form No.:
Hospital No:
Case No:
Room No:
Operation:
REGULAR IRREGULAR
LMP EDC
PMP OTHERS:
AOG
ALCOHOL INTAKE:
HEAVY OCCASIONAL
QUIT: YES NO
GENERAL
APPEARANCE
SKIN
HEENT
HEART
CHEST / LUNGS
ABDOMEN
RECTUM / GENITALIA
EXTREMITIES
NEURO
ADMITTING DIAGNOSIS: