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Republic of The Philippines Province of Rizal Medical-Dental Health Services

This 3 sentence summary provides the key details from the medical record document: The document is a medical record form from the University of Rizal System containing fields to record a patient's personal information such as name, birthdate, and medical history. It also includes sections for the university physician or nurse to document vitals, physical exam findings, remarks, and treatment recommendations. The form is dated and includes the patient's signature and the signature of the attending medical officer or nurse.

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Ces Reyes
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2K views1 page

Republic of The Philippines Province of Rizal Medical-Dental Health Services

This 3 sentence summary provides the key details from the medical record document: The document is a medical record form from the University of Rizal System containing fields to record a patient's personal information such as name, birthdate, and medical history. It also includes sections for the university physician or nurse to document vitals, physical exam findings, remarks, and treatment recommendations. The form is dated and includes the patient's signature and the signature of the attending medical officer or nurse.

Uploaded by

Ces Reyes
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Republic of the Philippines

University of Rizal System


Province of Rizal
MEDICAL-DENTAL HEALTH SERVICES

MEDICAL RECORD

Date: _________________
Name: ________________________________________________________________
(Surname) (Given Name) (M.I.)
Birthday: _________________ Age: ____ y/o Sex:_____
Civil Status: _______________ Religion: __________________
College: ___________ Course/Dept.:___________Student/Employee No.: _________________
Address: ______________________________________________________________________
Contact Person & # in case of emergency:__________________________________
MEDICAL HISTORY
Bronchial Asthma Epilepsy Hernia Heart Dse.
Last attack:__________________ Last attack:_________________
Allergies
Meds: ___________ Hospitalization/Surgery: _____________________
*FOR FEMALE ONLY
1st day of last menstrual period (LMP): (mm/dd/year)

To be filled-out by University Physician/Nurses


Height Weight BMI BP PR Temp
HEENT:
Chest/Lungs:
Heart:
Abdomen:
Extremities:
Others:
Remarks: ______________________________________________________________
Recommendation/s: _____________________________________________________

_______________________ ________________________
Patient’s Signature Medical Officer III / Nurse I
URS-AF-GE-MED-2017-05 Rev. 01 Effectivity Date: July 9, 2018

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