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Ticket No

Token No

Reporting Time at OHC

Followup to(if Applicable)

Injury Time

Incident Location

Complaints

Examination Findings

Remarks/Follow-up Investigation Details

Injury

Type	Part	Classification

Procedures (If Any):

Medicine Disbursement

Doctor Discussed?

Doctor Consulted?

Additional Recommendations(If Any)

Referral

Follow-up

Emergency? :

SBP:

DBP:

Temp:

FBS:

RBS:

PPBS:

SPOC2%:

Heart Rate:

Health Advices

Doctor Recommended Tests

Additional Precautions