Adult Patient Data1) Name Full Name 2) DOB MM slash DD slash YYYY 3) Phone4) Address Street Address City State / Province / Region 5) Nationality 6) Sex Male Female 7) Emergency ContactNameRelation to patientPhone Add Remove8) Date MM slash DD slash YYYY Medical Surgical History9) Allergies Yes No Environment Food Medication Others 10) Did you made any previous surgeries Yes No Specify Patient / Family history11) Family Cancer Diabetes GI Disorder Hypertension Hepatitis Lung Disease Tuberclosis CVA Epilepsy Heart Disease Blood Disorder Kidney Disease Behavioral problems Other 12) Patient Cancer Diabetes GI Disorder Hypertension Hepatitis Lung Disease Tuberlosis CVA Epilepsy Heart Disease Blood Disorder Kidney Disease Behavioral problems Other Other family disease Other patient disease 12) Services Needs Full care Tracheostomy care PEG care Folley care Colostomy Care Bedsore dressing Other 13) Psychological status Calm Cooperative Angry Depressed 14) Triage level 1 2 3 4 5 Height (CM)Weight (KG)Blood Group 15) Current Medication None yes List MedicationsName & doseFrequencyTime to take Add Remove16) Functional levelActivityDependentSelfcare Add RemovePain17) Problem Problem found No Problem VERBAL DESCRIPTION SCALE 1 2 3 4 5 6 7 8 9 10 Facial scale Location Description Increased By Decreased By Pain management Score Nursing Diagnosis18) Injury Description AB: Abrasion E: Ecchymosis B: Burn F: Fracture Am : Amputation R: Rash P: Puncture L: laceration S: Swelling
