, Brgy.

San Dionisio, City

WITH PHILHEALTH
MEMBERSHIP CATEGORY:____________________
HEALTHCARD: ____________________________

CLASSIFICATION:
HOUSE CASE
PRIVATE CASE
ATTENDING PHYSICIAN:________________

DATE:_____________________
TIME:_____________________

EMERGENCY ROOM RECORD

NAME OF PATIENT
LAST NAME

FIRST NAME

ADDRESS

DATE OF BIRTH

BED NO.

GENDER

CIVIL STATUS:

TEL. NUMBER

AGE

RELIGION:

MIDDLE NAME

OCCUPATION

MOBILE NUMBER

EMPLOYER NAME/ADDRESS:

NEXT OF KIN:

RELATIONSHIP TO THE PATIENT

ADDRESS

TEL. NUMBER

MOBILE NUMBER

PERSON / ORGANIZATION RESPONSIBLE FOR BILL/ADDRESS

TEL. NUMBER

MOBILE NUMBER

CONSENT TO TREATMENT: The UNDERSIGNED grants authority to THE PREMIER MEDICAL CENTER and its staff
to perform those procedure and treatments deemed necessary for the patient whose name appears above.
________________________________
Patients/Representatives Signature Over
Printed Name

CHIEF COMPLAINT:

HISTORY OF PRESENT ILLNESS

BP

PR

RR

TEMP

WEIGHT

HEIGHT

PHYSICAL EXAMINATION
HEENT
NECK
LUNGS/CHEST
ABDOMEN
EXTREMITIES
INTEGUMENTARY

GCS
EYE OPENING
VERBAL RESPONSE
MOTOR RESPONSE
TOTAL

4
5
6
15

DIAGNOSIS:

DOC NSD - 0002

PHYSICIANS ORDERS:
TIME

EFFECTIVE DATE: 02-03-2015

VITAL SIGNS MONITORING

BP
PR
RR
TEMP

DISCHARGE ORDERS
DISPOSITION
DATE
DISCHARGED

TIME

DAMA
ADMITTED
TRANSFERRED
TO HOSPITAL
_______________
EXPIRED

____________________________________M.D.

____________________________R.N.
DOC NSD - 0002

EFFECTIVE DATE: 02-03-2015