University of Science and Technology of Southern Philippines University of Science and Technology of Southern Philippines

Alubijid | Cagayan de Oro|Claveria |Jasaan | Oroquieta | Panaon|Villanueva Alubijid | Cagayan de Oro|Claveria |Jasaan | Oroquieta | Panaon|Villanueva

USTP-CDO-HS 12 USTP-CDO-HS 12

VITAL SIGNS RECORD FORM VITAL SIGNS RECORD FORM

NAME: _____________________________ AGE: ____ GENDER: ____ NAME: _____________________________ AGE: ____ GENDER: ____
ADDRESS: ___________________________________________________ ADDRESS: ___________________________________________________
CAMPUS: ______________________________ CAMPUS: ______________________________

*Vital Signs INITIAL DATE/TIME After 30 minutes *Vital Signs INITIAL DATE/TIME After 30 minutes
TAKEN (when applicable) (when applicable)
TAKEN
Blood pressure Blood pressure

Heart Rate Heart Rate

Respiratory Rate Respiratory Rate

Temperature Temperature

O2 Sat O2 Sat

Weight (kg) Weight (kg)

Height (cm) Height (cm)

Right eye Left eye With Without Right eye Left eye With Without
Visual Acuity glasses glasses Visual Acuity glasses glasses
(Snellen’s) (Snellen’s)

Name of health worker/nurse: Signature: Contact Name of health worker/nurse: Signature: Contact
number(s): number(s):

Name of Facility: Contact Name of Facility: Contact

numbers: numbers:

*Please recheck after 15 minutes if vital sign(s) is/are not within normal range. *Please recheck after 15 minutes if vital sign(s) is/are not within normal range.