DATA COLLECTION FORM

Patient name Age Gender

DEMOGRAPHICS

Date of Birth Height Weight

Room& Bed no Patient ID BMI

Date of admission Date of Discharge Race

Chief Complaint

Present Medical Illness

Past Medical History

OB&GYN History

Surgical History
Family History

Social History

Start Stop Indication Drug Name Actual Regimen Clinical Impressions

Date Date Strength
PAST MEDICATIONS
 Medication Allergies (Drug, timing, Reaction-Rash, Shock, asthma, nausea, anemia)
ALLERGIES

Adverse Reactions to drugs in the past

REVIEW OF SYSTEMS

Physical Exam
General Appearance Vital Signs

Skin HEENT

Chest Cardiac

Abdominal Genitalia/Rectal

Musculoskeletal &Extremities Neurologic

Labs
Lab History
Test Units Date: Date: Date: Date:

Pre -diabetes

FBS

RBS

PPBS

HbA1c

TSH

Free T4

FreeT3

Anti TPO

T. Cholesterol

HDL

LDL

TG
OTHER INVESTIGATIONS(IF

CTX,ECG,CT/MRI-Scan ,ECHO,USG etc….

ANY SPECIFY)

MEDICAL DIAGNOSIS
 Start Stop Indication Drug Name Actual Regimen Clinical Impressions
Date Date Strength
CURRENT MEDICATIONS