DATE*

AGE

PATIENTS ATTENDING STAFF NAME: "; while ($row3 = mysqli_fetch_array($result)) { echo ""; } echo ""; ?>

Location

INFORMATION BY

INFORMATION RECEVING TIME:

COMPLAINT OF PATIENT

Name

Employer/Contractor

PATIENT ATTENDING DOCTOR NAME: "; while ($row3 = mysqli_fetch_array($result)) { echo ""; } echo ""; ?>

AMBULANCE SENDING TIME:

PATIENTS IN TIME (HOSPITAL):

EXAMINE OF PATIENT'S/DIAGNOSIS:

VITAL SIGN:* BP mmHg, Pulse P/M, Spo2 %, RBS mg/dl, TEMP °F

GIVEN TREATMENT:

DISCHARGE TIME:

PATIENTS CONDITION ON DISCHARGE TIME