Medical Record No:

In Time

Case Type

Shift

Follow-up To(if Applicable)

Referred By

Complaints

Remarks/Follow-up Investigation Details

Examination Findings

Diagnosis

Ailment System

Medicine	Dosage	For Days	Qty	Price Per Unit	Stock	Issued	Total Price

Total Amount :

Medicine Disbursement

Yes

No

Referral

Follow-up

Emergency?

Chargeable?

Weight

Height

BMI

SBP

DBP

Temperature

Respiratory Rate

Heart Rate

Urine Output

FBS

RBS

PPBS

SPO2

AVPU

TRAMA

oxygen supplementation

glasgow coma scale

Mobility

Total Cholesterol

Affected Body Parts

Health Advices

Recommended Tests For Checkup

Additional Precautions