ST.

FRANCIS HOSPITAL
0NE SAN VICENTE WEST, URDANETA CITY, PANGASINAN

PHYSICAL EXAMINATION

Family Name First Name Middle Name Room No. Bed No. Hospital No.

Attending Physician Age Sex Civil Status

Check if findings are normal. Mark X in appropriate spaces in column at left if findings are abnormal, then describe at right.
SKIN
__Color __Eruption
__Moisture __Nails
__Texture __Nodules
__Pigment __Hair
__Ecchymosis __Others
__Petechiae
HEAD-EYES
__Conjunctiva __Fields
__Sclera __Ptosis
__Cornea __Exophtalmos
__Pupil __Lid-lag
__Movement __Tension
__Nytagmus __Ophthalmoscopic
__Acuity __Others
EARS
__Drums __Mastoid
__Hearing __Others
NOSE
__Airways __Sinus
__Mucose __Tenderness
__Septum __Trans illumination
__Others
MOUTH
__Breath __Tounge
__Lips __Salivary
__Teeth __Ducts
__Gums __Others
THROAT
__Tonsils __Post-nasal drip
__Pharynx __Others
NECK
__Stiffness __Vessels
__Masses __Trachea
__Thyroid __Others
LYMPH NODES
__Cervical __Inguinal
__Occipital __Epitrochlear
__Supraclavicular __Others
__Others
CHEST
__Shape __Respirations
__Symmetry __Others
BREAST
__Masses __Nipples
__Discharge __Others
HEART
__Apical Impulse __Sounds MI
__Thrill A2
__Pulsation Third
__Shock PE
__Rate __Murmurs
__Rhythm __Gallop
__Friction
 ST. FRANCIS HOSPITAL
0NE SAN VICENTE WEST, URDANETA CITY, PANGASINAN

PARENTERAL SHEET

Family Name First Name Middle Name Date Bed No. Hospital
Admitted No.

Attending Physician Room No. Age Sex Civil Status

DATE BOTTLE SOLUTION VOLUME RUNNING TIME REMARKS & DATE/TIME REMARKS &
NO. DRUGS INCORPORATED HOURS STARTED SIGNATURE CONS/DISC SIGNATURE
BLOOD TYPE & SERIAL
NO. (RED)
 ST. FRANCIS HOSPITAL
0NE SAN VICENTE WEST, URDANETA CITY, PANGASINAN

DISCHARGE SUMMARY

Date________________

Family Name First Name Middle Name Room No. Bed No. Hospital No.

Attending Physician Age Sex Civil Status

Date of Admission: Date of Discharge

FINAL DIAGNOSIS

____________________________________
Printed Name & Signature of Attending Physician

By__________________________________________
Printed Name & Signature of Resident Physician