DATE:_____________________TIME:_____________________CLASSIFICATION:HOUSE CASE PRIVATE CASE ATTENDING PHYSICIAN:________________ WITH PHILHEALTHMEMBERSHIP CATEGORY:____________________HEALTHCARD: ____________________________

Amvel Business Park, Brgy. San Dionisio, Sucat Road, Paranaque City

EMERGENCY ROOM RECORD

NAME OF PATIENTBED NO. GENDERCIVIL STATUS:RELIGION:

LAST NAMEFIRST NAME

MIDDLE NAME

ADDRESS

TEL. NUMBERMOBILE NUMBER

DATE OF BIRTHAGEOCCUPATIONEMPLOYER NAME/ADDRESS:

NEXT OF KIN:RELATIONSHIP TO THE PATIENT

ADDRESS

TEL. NUMBERMOBILE NUMBER

PERSON / ORGANIZATION RESPONSIBLE FOR BILL/ADDRESSTEL. 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:BPPRRRTEMPWEIGHTHEIGHT

HISTORY OF PRESENT ILLNESS

PHYSICAL EXAMINATION

HEENT

NECK

LUNGS/CHEST

ABDOMEN

EXTREMITIES

INTEGUMENTARY

GCS

EYE OPENING4

VERBAL RESPONSE5

MOTOR RESPONSE6

TOTAL15

DIAGNOSIS:

DOC NSD - 0002EFFECTIVE DATE: 02-03-2015

PHYSICIANS ORDERS:VITAL SIGNS MONITORINGTIMEBPPRRRTEMP

DISCHARGE ORDERS

DISPOSITIONDATETIME

DISCHARGED

DAMA

ADMITTED

TRANSFERRED TO HOSPITAL _______________

EXPIRED

____________________________________M.D.

____________________________R.N.

DOC NSD - 0002EFFECTIVE DATE: 02-03-2015