CITY GOVERNMENT OF LIGAO CITY GOVERNMENT OF LIGAO

LIGAO COMMUNITY COLLEGE LIGAO COMMUNITY COLLEGE

LiComCoClinic_Form No. 05 Tomolin, Ligao City, 4504 LiComCoClinic_Form No. 05 Tomolin, Ligao City, 4504
Rev: 01_2016 Email – Address: [email protected] Rev: 01_2016 Email – Address: [email protected]
Tel Nos.: 0926 – 772 - 1213 / (052) 431-4124 Tel Nos.: 0926 – 772 - 1213 / (052) 431-4124

INDIVIDUAL TREATMENT RECORD INDIVIDUAL TREATMENT RECORD

HEALTH & MEDICAL CARE SERVICES HEALTH & MEDICAL CARE SERVICES
Name: ______________________________________________________ Age: _____ Sex: ______ Name: ______________________________________________________ Age: _____ Sex: ______
Surname First Name M.I. Surname First Name M.I.
Date of Birth: ______________________ Place of Birth: ___________________________________ Date of Birth: ______________________ Place of Birth: ___________________________________
Address: __________________________________ Occupation (if any): _______________________ Address: __________________________________ Occupation: _____________________________
Parent/Guardian: _____________________ Contact No of Parent/Guardian :__________________ Parent/Guardian: _____________________ Contact No of Parent/Guardian :__________________

Pertinent Physical Examination Findings: Pertinent Physical Examination Findings:

BP: ____ PR ___ Height: _____ (cm) Weight : _____ (kg) Waist Circumference : ____ (cm) BP: ____ PR ___ Height: _____ (cm) Weight : _____ (kg) Waist Circumference : ____(cm)
Skin : pallor rashes jaundice good skin turgor Skin : pallor rashes jaundice good skin turgor
_____________________________________________________________________________________ _____________________________________________________________________________________
_____________________________________________________________________ _____________________________________________________________________
HEENT: anicteric sclerae intact tympanic membrane tonsillopharyngeal congestion HEENT: anicteric sclerae intact tympanic membrane tonsillopharyngeal congestion
Pupils briskly reactive to light alar flaring hypertrophic tonsils Pupils briskly reactive to light alar flaring hypertrophic tonsils
Nasal discharge palpable mass exudates aural discharge Nasal discharge palpable mass exudates aural discharge
________________________________________________________________________ ________________________________________________________________________
Chest/Lungs : symmetrical chest expansion retractions wheezes Chest/Lungs : symmetrical chest expansion retractions wheezes
clear breathsounds crackles/rales clear breathsounds crackles/rales
___________________________________________________________________ ___________________________________________________________________
Heart : adynamic precordium normal rate/regular rhythm heaves/thrills murmurs Heart : adynamic precordium normal rate/regular rhythm heaves/thrills murmurs
_________________________________________________________________________ _________________________________________________________________________
Abdomen : flat flabby tenderness globular muscle guarding palpable mass Abdomen : flat flabby tenderness globular muscle guarding palpable mass

_______________________________________________________________________ _______________________________________________________________________
Extremities : gross deformity normal gait full and equal pulses Extremities : gross deformity normal gait full and equal pulses

_______________________________________________________________________________ _______________________________________________________________________________
Diagnosis: Diagnosis:

Medication/Treatment: Medication/Treatment:

Laboratory Findings: Laboratory Findings:

HEALTH CARE PROVIDER: HEALTH CARE PROVIDER:

REMARKS: REMARKS:
__________________________________________________________________________________ __________________________________________________________________________________
__________________________________________________________________________________ __________________________________________________________________________________
__________________________________________________________________________________ __________________________________________________________________________________
__________________________________________________________________________________ __________________________________________________________________________________
__________________________________________________________________________________ __________________________________________________________________________________
__________________________________________________________________________________ __________________________________________________________________________________
__________________________________________________________________________________ __________________________________________________________________________________
__________________________________________________________________________________ __________________________________________________________________________________
__________________________________________________________________________________ __________________________________________________________________________________
__________________________________________________________________________________ __________________________________________________________________________________
__________________________________________________________________________________ __________________________________________________________________________________
__________________________________________________________________________________ __________________________________________________________________________________
__________________________________________________________________________________ __________________________________________________________________________________
__________________________________________________________________________________ __________________________________________________________________________________
__________________________________________________________________________________ __________________________________________________________________________________
__________________________________________________________________________________ __________________________________________________________________________________
__________________________________________________________________________________ __________________________________________________________________________________
__________________________________________________________________________________ __________________________________________________________________________________
__________________________________________________________________________________ __________________________________________________________________________________
__________________________________________________________________________________ __________________________________________________________________________________
__________________________________________________________________________________ __________________________________________________________________________________
__________________________________________________________________________________ __________________________________________________________________________________
__________________________________________________________________________________ __________________________________________________________________________________
__________________________________________________________________________________ __________________________________________________________________________________
__________________________________________________________________________________ __________________________________________________________________________________
__________________________________________________________________________________ __________________________________________________________________________________
__________________________________________________________________________________ __________________________________________________________________________________