Patient Health Records - Haiti Outreach Ministries

Clinique de Sante Communautaire de l’Eglise Chretienne des Cities
Haiti Outreach Ministries/Mission Communautaire de l’Eglise Chretienne des Cites
PATIENT HEALTH RECORD
Nom De Famille:
Sexe: H/F L’Age:
Prenom:
Date De Naissance: (J/M/A)
Paran (pou timoun) oswa yon kontak ijans
Telefòn
Parent (for children) or emergency contact
Adresse:
Telefòn
HX (Circle) HTN DM Seizures Asthma Anemia GERD Other:_____
Vaccinations: TDap
Hep A/B Polio MMR
BHG
OB/GYN: P
G
A
Kantite moun ki vivan
(Number of living children)
Medications:
DATE:
BP:
CC: Fever Weakness Dizziness HA Pain
MUAC:
HR:
Resp:
(Green, Yellow, Red) BS:
BP:
CC: Fever Weakness Dizziness HA Pain
MUAC:
Weight:
kg
lb
Rash Cough SOB Vaginal: D/C Odor N&V Diarrhea GERD Other::
mg/dl U/A Pregnancy:
Retounen nan klinik (Return to Clinic) Date:
DATE:
Temp:
HR:
U/A: Protein Glucose Blood Leukocytes
Doktè (Doctor)
Resp:
Temp:
Weight:
kg
Rash Cough SOB Vaginal: D/C Odor N&V Diarrhea GERD Other:
(Green, Yellow, Red) BS:
mg/dl U/A Pregnancy:
U/A: Protein Glucose Blood Leukocytes
9
Retounen nan klinik (Return to Clinic) Date:
Doktè (Doctor)
lb
Clinique de Sante Communautaire de l’Eglise Chretienne des Cities
Haiti Outreach Ministries/Mission Communautaire de l’Eglise Chretienne des Cites
PATIENT HEALTH RECORD
DATE:
BP:
CC: Fever Weakness Dizziness HA Pain
MUAC:
HR:
Resp:
(Green, Yellow, Red) BS:
BP:
CC: Fever Weakness Dizziness HA Pain
MUAC:
9
mg/dl U/A Pregnancy:
HR:
CC: Fever Weakness Dizziness HA Pain
MUAC:
9
lb
U/A: Protein Glucose Blood Leukocytes
Resp:
Temp:
Weight:
kg
lb
Rash Cough SOB Vaginal: D/C Odor N&V Diarrhea GERD Other:
(Green, Yellow, Red) BS:
BP:
kg
Doktè (Doctor)
mg/dl U/A Pregnancy:
Retounen nan klinik (Return to Clinic) Date:
DATE:
Weight:
Rash Cough SOB Vaginal: D/C Odor N&V Diarrhea GERD Other::
Retounen nan klinik (Return to Clinic) Date:
DATE:
Temp:
HR:
U/A: Protein Glucose Blood Leukocytes
Doktè (Doctor)
Resp:
Temp:
Weight:
kg
Rash Cough SOB Vaginal: D/C Odor N&V Diarrhea GERD Other:
(Green, Yellow, Red) BS:
mg/dl U/A Pregnancy:
U/A: Protein Glucose Blood Leukocytes
9
Retounen nan klinik (Return to Clinic) Date:
Doktè (Doctor)
lb