Medical Clinic Information Sheet .docx

MEDICAL CLINIC Information Sheet KINDLY READ Data gathered from this form will be used by Medical Clinic for the patient’s diagnosis and treatment. We will handle the information with confidentiality. Incomplete/false information may result in misdiagnosis of the patient. To be filled up by the patient/relative/ companion Date:________________ SURNAME: ______________ FIRST NAME: _________________ MIDDLE NAME _________ Age: ______ Sex: ________ Birthday: ______________ Birthplace: _______________________ Address: _____________________________________ Cellphone Number:_________________ Email address: ______________________Occupation (Current/Previous): __________________ Religion: ________________ Marital Status (Single/Married/Widow/Widower): ___________ Name of Companion: _______________ Relation to Patient _________ Contact #: ___________ Patient’s Medical History Disease Asthma (Bronchial, Skin) Tuberculosis Pneumonia Hypertension Thyroid disease Diabetes Cancer Steven Johnson Syndrome/ Toxic necrotising epidermolysis Stroke Kidney Disease Hepatitis Sexually Transmitted Disease (AIDS/ Gonorrhea/ Syphillis) Psychiatric Disease

YES

NO

Year Diagnosed

Other Diseases: __________________________________________________________________ _______________________________________________________________________________ Previous Operation: (kind of operation/ Year performed/ Hospital)__________________________ _______________________________________________________________________________ Previous Blood Transfusion • YES • NO. If yes: Kindly indicate Number of bags transfused/date/hospital where transfusion done ________________________________________ Are you allergic to any medication: • YES • NO. Request for additional paper if needed. Allergic medication Date of Last Intake Symptoms

Any other allergies (Food/pollen/etc)? _________________________________ Immunization History (request for additional paper if needed) Vaccine Dose given Date given