Republic of the Philippines

PROVINCIAL HEALTH OFFICE

ILOCOS SUR PROVINCIAL HOSPITAL – GABRIELA SILANG
Vigan City

RADIOLOGY REQUEST FORM

X- RAY ULTRASOUND CT-SCAN  MRI/ECG PORTABLE

DATE: 12/07/2021
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HOSPITAL CASE NO. 2021-1002 FILM NUMBER: 110089
WARD: OPD_________
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. PHILHEALTH CLASSIFICATION: PRIVATE
NAME OF PATIENT: PASCUA MARITES RABUT_____
FAMILY NAME GIVEN NAME MIDDLE NAME
ADDRESS: BARANGAY X, VIGAN CITY AGE: 52 SEX: F CIVIL STATUS: Married
DATE OF BIRTH: September 21, 1969___

Pertinent History and Clinical Findings: There was an increased occurrence of LVH, ST depression and T wave
invasion in chronic hypertensive than controls.

Previous X-RAY, CT SCAN, MRI, ULTRASOUND in ISPH-GS WARD: N/A YES DATE: N/A

CLINICAL DIAGNOSIS: DIABETES MELLITUS TYPE 1 WITH HYPERTENSION TYPE 1____________________

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EXAMINATION DESIRED: HEART__________________________________________________________

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SHEENA MARI SABADO 12/07/21 DR. KAYE QUILALA

RADIOLOGIC TECHNOLOGY/ DATE PERFORMED Requesting Physician
RADIOLOGIST (signature Over Printed Name)
RAD-012-0