ADMISSION TO A HOSPITAL

• Collect data from patient

• Use questions to collect data to fill in the admission
form
 PATIENT’S IDENTITY
 SURNAME :
 SEX/GENDER : F / M
 AGE :
 DATE OF BIRTH :
 MARITAL STATUS/CIVIL STATE:
 ADDRESS :
 TELEPHONE / PHONE NUMBER :
 RELIGION :
 OCCUPATION :
 NEXT OF KIN:
 IDENTITY
 NAME : First Name / Sure Name/Family Name Full Name
 What’s your surname/first name/full name ?
 How do you spell it ?

 GENDER : M / F
 AGE
 How old are you?

 DOB (DATE Of BIRTH)

 When were you born
 Your date of birth please
 MARITAL STATUS/CIVIL STATE: (Married, single, widow, widower,
divorcee)
 Are you married
 ADDRESS :
 where do you live ?
 What’s your email address?
 TELEPHONE / PHONE NUMBER :
 What is your phone number?
 RELIGION :
 what is your religion? (Moslem, Christian, Budhism , Hidhuism,
 OCCUPATION :
 What is your occupation?
 NEXT OF KIN:
 What’s your nearets relative/ Relationship to you ?
 Who’sYour next of kin?
 Prabowo’s Medical Centre Hospital Reg. No. : …………………………….
Addmisson Card
Ward / Dept. : ………………………………

Title:………….. First Name : ………………… Surname:……………… Sex/Gender: ……. Marital Status:…………

Address : ………………………………………..

Date of Birth : ……………………………………… Religion : ……………………………………………

Phone number: ………………………………………. Email : ……………………………….

Occupation : ………………………………………….. Education : ……………………………………………..

Next of Kin : ………………………………. Relationship to patient: …………………………………. .

 Hospital Reg. No. : …………………………….
Prabowo’s Medical Centre
Admisson Card Ward / Dept. : ………………………………

Title:………….. First Name : ………………… Surname:……………… Sex/Gender: ……. Marital

Status:…………….. Address : ………………………………………..

Date of Birth : ……………………………………… Religion : ……………………………………………

Phone number: ………………………………………. Email : ……………………………….

Occupation : ………………………………………….. Education : ……………………………………………..

Next of Kin : ………………………………. Relationship to patient: …………………………………..

Chief / Present Complain :

POINT OF NOTE
Site :

Duration :

Precipitating factors :

Relief of Pain :

Accompanying symptom:

Immediate Past History :

VITAL SIGN
Blood Pressure :

Body Temperature :

Pulse :

Respiration :

Diagnosis Management/Intervention

Date: Nurse: