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SREENING & VITAL SIGNS

Case Number:

Last Name

First Name

Date of Birth

Sex

I. REVIEW OF SYSTEMS

1. Chief complaint (please describe)

2. Do you experience any of the following: fever, cough, colds, or headache?

Yes

3. Do you experience any of the following: unexplained change in weight, loss of appetite, change in bowel movement, or abdominal pain?

Yes

4. Do you experience any of the following: chest pain or difficulty in breathing?

Yes

5. Do you experience any of the following: frequent urination, frequent eating, frequent intake of fluids, smoking and drinking alcohol?

Yes

6. Do you experience any of the following: pain or discomfort on urination or frequency of urination?

Yes

7a. Last menstrual period:

7b. First menstrual period:

8. Do you experience any of the following: muscle spasm, tremors, weakness; muscle/joint pain, stiffness, limitation of movement?

Yes

If yes, please explain:

7c. Number of pregnancy:

7d. Number of delivery:

If yes, please explain:

If the answer is yes to Questions 1-8, the beneficiary needs to consult a doctor.

II. PERSONAL & SOCIAL HISTORY

1. Do you smoke cigar, cigarette, e-cigarette, vape, or other similar products?

Yes

2. Do you drink alcohol or alcohol-containing beverages?

Yes

If yes, how many years:

III. PAST MEDICAL EXAMINATION

Choose all that applies:

Cancer

Allergies

Diabetes Mellitus

Hypertension

Heart Disease

Stroke

Bronchial asthma

COPD/emphysema/bronchitis

Tuberculosis

None

Others

IV. PERTINENT PHYSICAL EXAMINATION FINDINGS

Systolic BP

Diastolic BP

Heart Rate:

Resp Rate

Height:

Weight:

Temperature:

Length:

Skinfold:

Head Circum:

Waist Circum:

Hip Circum:

Limb Circum:

Middle & Upper Arm

General Survey:

Awake and alert

Altered Sensorium

Blood Type (as available)

A+

B+

AB+

O+

A-

B-

AB-

O-

Thanks for submitting!

telecure, medical, diagnostics, laboratory, consultation, telemedicine, vaccination, vaccine, APE, PEME

SREENING & VITAL SIGNS

I. REVIEW OF SYSTEMS

II. PERSONAL & SOCIAL HISTORY

III. PAST MEDICAL EXAMINATION

IV. PERTINENT PHYSICAL EXAMINATION FINDINGS

221 Tanjeco St., San Vicente, City of Malolos, Bulacan

09171835980
(044) 305 4492

support@telecure.com.ph