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Emergency Patient Assessment Form

The document is an emergency patient assessment form from Lifecare Hospital. It collects information such as the patient's name, address, doctor in charge, primary complaint, allergies, past and present medical history including conditions like diabetes, hypertension, cancer, and whether they have tested positive for tuberculosis, corona, or have breathing difficulties. It also documents any laboratory tests ordered and the treatments prescribed including medications, dosage, route, frequency, and time to be taken. The form is to be signed and dated.

Uploaded by

mohamed elgabry
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© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOCX, PDF, TXT or read online on Scribd
1K views2 pages

Emergency Patient Assessment Form

The document is an emergency patient assessment form from Lifecare Hospital. It collects information such as the patient's name, address, doctor in charge, primary complaint, allergies, past and present medical history including conditions like diabetes, hypertension, cancer, and whether they have tested positive for tuberculosis, corona, or have breathing difficulties. It also documents any laboratory tests ordered and the treatments prescribed including medications, dosage, route, frequency, and time to be taken. The form is to be signed and dated.

Uploaded by

mohamed elgabry
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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LIFECARE HOSPITAL

EMERGENCY PATIENT ASSESSMENT FORM

NAME OF PATIENT……………………………………………………………………………………CONTACT…………………………………..

ADRESS……………………………………………………………………………………………………………………………………......................

DOCTOR IN CHARGE …………………………………………………………………………………………………………………………………

PRIMARY COMPLAINT

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ALLERGIES………………………………..

PAST MEDICAL HISTORY PRESENT MEDICAL HISTORY


CONDITION YES NO IF YES DATE CONDITION YES NO IF YES DATE
Diabetes Diabetes
Hypertension Hypertension
Stroke Stroke
Cancer Cancer
Hepatitis Hepatitis
Seizure Seizure
Positive TB test Positive TB test
Breathing difficulties Breathing difficulties
Chronic Cough Chronic Cough
Corona Positive Test Other

LABORATORY REQUEST ORDERED

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TREATMENT ORDERED

MEDICATION: DOSAGE, TIME TOBE DATE AND SIGNATURE


ROUTE,FREQUENCY TAKEN

Note………………………………………………………………………………………………………………………………………………………………………

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