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  • TRTR Tru Utr: Xueustn, Lffi

    Încărcat de

    Nikki Ticman
    13 vizualizări1 pagină
    This medical form collects personal information such as name, age, address, and contact details. It includes sections for physicians to record results from a physical examination, including vital signs, vision, heart and lung auscultation, abdominal and skin examinations. The form concludes with space for the physician's diagnosis, recommendations, and contact information.

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    This medical form collects personal information such as name, age, address, and contact details. It includes sections for physicians to record results from a physical examination, including vital signs, vision, heart and lung auscultation, abdominal and skin examinations. The form concludes with space for the physician's diagnosis, recommendations, and contact information.

    Drepturi de autor:

    Attribution Non-Commercial (BY-NC)
    Descărcați ca PDF, TXT sau citiți online pe Scribd
    Indicator pentru conținut neadecvat
    13 vizualizări1 pagină

    TRTR Tru Utr: Xueustn, Lffi

    Încărcat de

    Nikki Ticman
    This medical form collects personal information such as name, age, address, and contact details. It includes sections for physicians to record results from a physical examination, including vital signs, vision, heart and lung auscultation, abdominal and skin examinations. The form concludes with space for the physician's diagnosis, recommendations, and contact information.

    Drepturi de autor:

    Attribution Non-Commercial (BY-NC)
    Descărcați ca PDF, TXT sau citiți online pe Scribd
    Indicator pentru conținut neadecvat
    din 1

    Note: Do nd PHOTOCOPY this form. lt should be dornbaded and ginted direcflyfrqn fie DLSU Online Fresfiman Examinalim Page.

    The online page shwH be flled-up INDIVIDUALLY firs{.

    De La Salle University
    MEDICAL

    IflD

    DEIITAL

    FORM B
    NAME:

    ':RYICES
    JAMILARTN

    TICMAN

    Age:

    16

    **'Yrot"^---

    NADTNE E ^.6,&. xueustn,lffi* Date of Birth:


    MTKHATLA

    Middlenane
    Gender:

    FEMALE 65&09-61

    Address: 42 DOVVNHILL ST., TOWERHILLS SUBD,, BRGY. DOLORES, TAYTAY RITAL

    contact No.:

    lnstnrcdonsfotPhydctan:.Fitloutallsectionsof thisform.To record dotafrom patien*Physicol Etamination, pleaxtick


    appropriate boxes ond fill-up the necesmry information.

    fieviuof

    Systemr:

    I headache fl migraine D diziness I blurringofvision fl visual loss

    fJ

    dyspnea

    fJ

    ft

    tachypnea cough hemoptysis chestpain palpitations easllyfatigued

    E I I f] ! I I

    hyperacidity dysmenorrhea

    lossofappetite
    hematochezia melena hematemesis dysuria

    I I fl I I I fl I I I fl

    weakness

    deficit
    hallucination
    syncope

    fl fl hearingimpairment I fl difficultyofbreathing I frequency I nose bleeding fl tinnitus I neckpain fl abdominalpain fl colds E backpain I constipation ! muscle pain I diarrhea vomiting I I joint pain

    fJ

    convulsion
    depression

    fever chills
    malaise

    jaundice others

    Physkal Examlnation
    Blood Pressure
    Pulse Rate Resp. Rate

    Height (in inches)

    Weight{in pounds)
    Blood Type LMP
    {ptease bring otficiat resuk)

    Temperature
    Eye

    Examination
    {u

    Right

    Lft No

    Visual Acuity

    ting sndbn

    Anft)

    Yes

    Contact Lens
    Glasses

    Color Elind Head and Neck


    EENT

    trtr tru utr

    Normal

    Abnormal findinqs Heart

    Normal

    Abnormal findinqs

    AMomen
    Extremities

    Chest/ Lungs
    Breast
    Chest X ray resultstuust
    have beet talan wfthIn the tast

    Eldt-hattud ilRw-handd
    Skin

    six(6)nontlx)
    Date

    ln vietrr of the student's history and physical eromination, is it your assessment that his / her health status is adequate for studies / school activities, without restrictions? E E ruo

    yes

    lf with restrictiont what are your recommendationsT

    Other remark:
    Diagnosis:
    Flria. PhysicianS Name and Signature; License Number:

    Contact Number:

    Clinic Address:

    tualrfuThtsform

    mustbe submlttedtotheUnlvedry Ahic togcther withthe oficial ch6tx-roy ond bloodtype rxuh.

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