Zone 1, Zone 1 Andres Bonifacio St,

Baybay City, 6521 Leyte

Phone No. 0926-799-4147
Fb: rabiesbusterABC
Email: rabiesbusteranimalbiteclinic@gmail.com

PATIENT RECORD
DATE: ______________ TIME:______________ PHIC MEMBER ( )YES ( )NO
PHIC MEMBER (PIN)_____________________ (PHIC DEPENDENT PIN)______________________________
FIRST NAME:_________________ MIDLE NAME________________ SURNAME_____________________
BIRTHDAY______________ AGE:_____SEX:____ OCCUPATION:____________ CONTACT NO.___________
Px ADDRESS: ____________________________________________________________________________
STREET BRGY. MUNICIPALITY/CITY PROVINCE

Weight (kg): Temp: PR: bpm RR: cpm SPO2 %: ____________ @

BP: L-Arm _______________ mmHg R-Arm ________________ mmHg Lower-Ext. ____________ mmHg

A. BITING ANIMAL: _____________________

( ) Pet ( ) Stray ( ) Stray
Rabies Immunization: 1st :____________________
2nd: ____________________
Status of biting animal:
( ) Alive ( ) Killed ( ) unexplained Death ( ) Cannot be observed

B. HUMAN BITE PATIENT:

Date of Biting Incidence: _______________ Place Exposure: _____________________________

( ) Provoked ( ) Unprovoked
Bite Site and Description: ___________________
( ) Abrasion ( ) Laceration ( ) Punctured ( )Scratch Others: _____________________
Wound Severity
( ) Single ( ) Multiple
Spontaneous Bleed: ( ) Yes ( ) No
Anti-Rabies Vaccination History: _______________________
Co-Morbidities:____________________________

C. TETANUS VACCINE HISTORY:

( ) Yes ( ) No No. Of Doses: _____

A: _________Bite, Rabies vaccine PEP, CAT ___

Plan:
1. ( ) Washing of bites with soap and running water for 10 mins. Wound care advised

2. ERIG (Equirab) 200IU/ml, _____ml infiltrated to bites sites. ANST ( )

Batch/Lot # __________________
3. ARV PVRV/PCECV (Speeda/vaxirab) 0.1ml ID x 2 Deltoids;
D0: ____________________ Batch_____________
D3: ____________________ Batch _____________
D7: ____________________ Batch_____________
D28:___________________ Batch _____________

4. Observe biting animal until _________________