DATE: __________ CHIEF COMPLAINTS: ________________ DATE: __________ CHIEF COMPLAINTS: ________________

APELYIDO: ________________________________________ APELYIDO: ________________________________________

PANGALAN: ____________________________ AGE: ______ PANGALAN: ____________________________ AGE: ______

MIDDLE NAME: _________________________ SEX: ______ MIDDLE NAME: _________________________ SEX: ______

ADLAW NATAWHAN: _______________ CIVIL STATUS: ____ ADLAW NATAWHAN: _______________ CIVIL STATUS: ____

V/S: PR _______ RR ______ TEMP ________ O2SAT_______ V/S: PR _______ RR ______ TEMP ________ O2SAT_______

HEIGHT: ______ cms WEIGHT: _____ kgs BP: ________mmHg HEIGHT: ______ cms WEIGHT: _____ kgs BP: ________mmHg

DATE: __________ CHIEF COMPLAINTS: ________________ DATE: __________ CHIEF COMPLAINTS: ________________

APELYIDO: ________________________________________ APELYIDO: ________________________________________

PANGALAN: ____________________________ AGE: ______ PANGALAN: ____________________________ AGE: ______

MIDDLE NAME: _________________________ SEX: ______ MIDDLE NAME: _________________________ SEX: ______

ADLAW NATAWHAN: _______________ CIVIL STATUS: ____ ADLAW NATAWHAN: _______________ CIVIL STATUS: ____

V/S: PR _______ RR ______ TEMP ________ O2SAT_______ V/S: PR _______ RR ______ TEMP ________ O2SAT_______

HEIGHT: ______ cms WEIGHT: _____ kgs BP: ________mmHg HEIGHT: ______ cms WEIGHT: _____ kgs BP: ________mmHg

DATE: __________ CHIEF COMPLAINTS: ________________ DATE: __________ CHIEF COMPLAINTS: ________________

APELYIDO: ________________________________________ APELYIDO: ________________________________________

PANGALAN: ____________________________ AGE: ______ PANGALAN: ____________________________ AGE: ______

MIDDLE NAME: _________________________ SEX: ______ MIDDLE NAME: _________________________ SEX: ______

ADLAW NATAWHAN: _______________ CIVIL STATUS: ____ ADLAW NATAWHAN: _______________ CIVIL STATUS: ____

V/S: PR _______ RR ______ TEMP ________ O2SAT_______ V/S: PR _______ RR ______ TEMP ________ O2SAT_______

HEIGHT: ______ cms WEIGHT: _____ kgs BP: ________mmHg HEIGHT: ______ cms WEIGHT: _____ kgs BP: ________mmHg

DATE: __________ CHIEF COMPLAINTS: ________________ DATE: __________ CHIEF COMPLAINTS: ________________

APELYIDO: ________________________________________ APELYIDO: ________________________________________

PANGALAN: ____________________________ AGE: ______ PANGALAN: ____________________________ AGE: ______

MIDDLE NAME: _________________________ SEX: ______ MIDDLE NAME: _________________________ SEX: ______

ADLAW NATAWHAN: _______________ CIVIL STATUS: ____ ADLAW NATAWHAN: _______________ CIVIL STATUS: ____

V/S: PR _______ RR ______ TEMP ________ O2SAT_______ V/S: PR _______ RR ______ TEMP ________ O2SAT_______

HEIGHT: ______ cms WEIGHT: _____ kgs BP: ________mmHg HEIGHT: ______ cms WEIGHT: _____ kgs BP: ________mmHg

DATE: __________ CHIEF COMPLAINTS: ________________ DATE: __________ CHIEF COMPLAINTS: ________________

APELYIDO: ________________________________________ APELYIDO: ________________________________________

PANGALAN: ____________________________ AGE: ______ PANGALAN: ____________________________ AGE: ______

MIDDLE NAME: _________________________ SEX: ______ MIDDLE NAME: _________________________ SEX: ______

ADLAW NATAWHAN: _______________ CIVIL STATUS: ____ ADLAW NATAWHAN: _______________ CIVIL STATUS: ____

V/S: PR _______ RR ______ TEMP ________ O2SAT_______ V/S: PR _______ RR ______ TEMP ________ O2SAT_______

HEIGHT: ______ cms WEIGHT: _____ kgs BP: ________mmHg HEIGHT: ______ cms WEIGHT: _____ kgs BP: ________mmHg