CANBURY HOSPITAL

234 ,Happy Garden Street, Aucland, United Kingdom

ADMISION FORM

Client’s Personal Identity

1.Name
a. Complete name What is your complete
name?
b. Last name / family What is your last name?
name
c. Middle Name What is your middle name?
d. Nick Name What is your nick name?

2. Religion What is your believe?

3. Nationality What is your nationality?

4. Date of birth When were you born?/ your

date of birth please.

5. place of birth When were you born?

6. Address / Residence Where do you live?/ where

do you stay? Where is your
residence?

7. Civil State What is your civil state?

8. Next of kin / spause Who is your next of kin?

9. Relation What is your relation with

her/him?

10. Address of next of kin Do you live at the same

address?

11. Telephone Number Any contack person in

emergency case?

12. Name of GP Who is your general

practioner?

13. Address of G.P Where do you live?

14. Hospitalization Yes / no

History : For what reason?
Reason : When was it?
 Time
15. Surgical history Have you ever been
operated before?
Reason : have you ever had surgery
before?
Time : when was it?

II. Date of admission 18/06/2020

1. Reason of admission / What make you come here?

chief complaint
2. Duration Hong long have you go it?
3. Location Where do you feel the pain?/
how do you feel it?
4. Severity / description How do you feel it?
How do you feel the pain?

III. Alergy Do you have allergy?

1. Specific Tell me the specific foof?
2.
IV. Medication History Tell me your medication
history?
II1.1. medicine’s name Tell me the name of medicine?/
what mdicine do you take?
Iv 2. Last time taken When did the last time you
take it?
3 3. disabilities Do you have disabilities and
need assistant?
VV. Bowel / Pass Stool
1. Bowel problem Do you have any problems with
you bowel problem?
2. Frequency When was it?
VI. bladder Problems / Pass
Urine / Water work
1. Bladder Problems Do you have any problems with
you bowel problem?
2. Frequency When was it?

PHYSICAL EXMINATION
RESULT ( OBSERVATION )

VISION NORMAL / NO ABNORMALITIES

HEARING
WEARING DENTURES / N/ A
ORAL
ADMISSION VITAL SIGN
T:
P:
R:
 B/ P :
h/r
LEVEL OF CONSCIOUSNESS
AWARE

COMPOSMENTIS / FULLY
AWARNESS
GCS
DECREASE LEVEL OF
CONSCIOUSNESS
GENERAL APPEARANCE

……………………………………..

GOOD
WEAK
LACK
POOR