CORROMPIDO GENERAL HOSPITAL

Leopoldo Regis St., Zone V Sogod, So. Leyte

OUT PATIENT DEPARTMENT
DATE: _______________

NAME:________________________________AGE: _____CS:_______ Time of Arrival :__________

ADDRESS:________________________________________________________ Time of Extraction :__________
BIRTHDAY: ____________________________ CONTACT NO. _______________ Time of Result :__________
Time of Queuing :__________
COMPLAINT/PROBLEM: __________________________________________________

BP_______ MMHG______ BPM//RR ________ CCPM//T _________CPM //

T_______ °C//02 SAT ______ % HT ________ CM/FT-IN//WT:_________KG/LB//

ALLERGIES:______________________________________________________________

CBC UA S/E BLOOD FBS CHOLESTERO LIPID CREA BUN BUA ULTRASOUND ELECTROLY FOBT
TYPING
L PANEL TE PANEL

WHOLE
ABDOMEN
(W/PG)
SGPT SGOT CBG HBA1C TSH T3 T4 ECG XRAY H- KUG (W/PG)
PYLORI
HBT

CORROMPIDO GENERAL HOSPITAL

Leopoldo Regis St., Zone V Sogod, So. Leyte
OUT PATIENT DEPARTMENT
DATE: _______________

NAME:________________________________AGE: _____CS:_______ Time of Arrival :_________

ADDRESS:_________________________________________________________ Time of Extraction :_________
BIRTHDAY: ____________________________ CONTACT NO. _______________ Time of Result :_________
Time of Queuing :_________
COMPLAINT/PROBLEM: ___________________________________________________

BP_______ MMHG______ BPM//RR ________ CCPM//T _________CPM //

T_______ °C//02 SAT ______ % HT ________ CM/FT-IN//WT:_________KG/LB//

ALLERGIES:______________________________________________________________

CBC UA S/E BLOOD FBS CHOLESTERO LIPID CREA BUN BUA ULTRASOUND ELECTROLY FOBT
TYPING
L PANEL TE PANEL

WHOLE
ABDOMEN
(W/PG)
SGPT SGOT CBG HBA1C TSH T3 T4 ECG XRAY H- KUB (W/PG)
PYLORI
HBT
 Corrompido General Hospital
Leopoldo Regis St., Zone V Sogod, So. Leyte
OUT PATIENT DEPARTMENT
DATE: _________
NAME:_______________________________________ AGE: _____ CS:_________
ADDRESS:__________________________________________________________________________
BIRTHDAY: ____________________________________ CONTACT NO. __________________

COMPLAINT/PROBLEM: ______________________________________________________________

BP_______ MMHG______ BPM//RR ________ CCPM//T _________CPM //

T_______ °C//02 SAT ______ % HT ________ CM/FT-IN//WT:_________KG/LB//
ALLERGIES:______________________________________________________________

CBC UA S/E BLOOD FBS CHOLESTEROL LIPID CREA BUN BUA

TYPING
PANEL

SGPT SGOT CBG HBA1C TSH T3 T4 ECG XRAY H-PYLORI

FRUIT
SALAD
Ᵽ10