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Slide 4 - Patient Admission Form-1
Slide 4 - Patient Admission Form-1
MODULE 3
Pre-advance level
for S-1 Nursing Students 2008
DIEN’s
Hospital admission
Address
Place of employment
Occupation
The data may also include:
Details of any medicines the patient has taken
Details of your general practitioner or other
treating health professionals
Reason for hospitalization
Allergies to medications or foods
Emergency contact information, or the names
and telephone numbers of those individuals
the hospital should contact if the person being
admitted needs emergency care or their
condition worsens significantly
Insurance coverage
Religious preference, including whether or not
one wishes a clergy member to visit
NOTES
There may be several forms to fill out.
One form may be a detailed medical and
medication history.
This history will include past hospitalizations
and surgeries.
Once all the admitting information has been
completed, the next step is usually being
taken to a room.
1
Useful Expressions
What can I do for you / May I help you? I want to
consult about my health problem.
What’s your name? My name is John Denver.
Fill out this form, please.
What is your complaint? I have a fever.
How long have you had fever? I have had it for 3
days.
What medicine have you taken? I have taken
Paracetamol.
Have you visited your GP before coming here? Yes,
I have.
What is your GP’s name? Dr. Richardson
What is your GP’s address? Pahlawan 20 Sby
What is your GP’s phone number? 031-457367468
Useful Expressions
Whom should I call in emergency condition?
Mr. Sanderson
Name (mention) your emergency contact person.
What is your relation wth your contact person? He is my
father.
Do you have any allergies? Yes, I do / No, I don’t
Are you allergic to certain food? Yes. I’m allergic to
seafood.
Are you allergic to certain medicine? No, I am not.
Are you allergic to certain substance? No , am not.
Do you have any insurance? Yes, I do.
What’s your insurance name? It is Jamsostek.
THANKS for your attention