VITAL SIGNS
Health #	202590007	Date
Height			Weight
Blood Pressure			Blood type	Type O- O+ A- A+ B- B+ AB- AB+
Heart Rate			Respiratory Rate
Temperature			BMI
Eye Acuity	Right Eye		Left Eye
Sexually Active?	Select Yes No
Immunization	Select None BCG OPV1 OPV2 OPV3 DPT1 DPT2 DPT3 Hepatitis B1 Hepatitis B2 Hepatitis B3 Hepatitis A Chicken Pox HPV MMR Tetanus Toxoid Chicken Pox Flu Vaccine
Past Medical History	Select None Allergy Asthma Cancer Cerebrovascular Diasease Diabetes Millitus Epilepzy/Seizure Disorder Hyperlipidemia Hypertension Peptic Ulcer Penumonia Thyroid Dieases Pulmunary Tuberculosis Urinary Tract Infection Mental Illness Others
Specific
Family Med History	Select None Allergy Asthma Cancer Cerebrovascular Diasease Diabetes Millitus Epilepzy/Seizure Disorder Hyperlipidemia Hypertension Peptic Ulcer Penumonia Thyroid Dieases Pulmunary Tuberculosis Urinary Tract Infection Mental Illness Others
Specific
Smoking?	Select Yes No Quit
Alcohol?	Select Yes No Quit
ILLicit drugs.?	Select Yes No Quit
Access on Family Planning?		Select Yes No
1. Chief Complaint
2. Do you experience any of the following: Loss of Appetite, Lack of Sleep, unexplained weight Loss, feeling down/ depressed, fever, headache, memory loss, blurring of vision,or hearing loss?
Select Yes No
3. Do you experience any of the following: cough / colds, chest pain, palpitations, or difficulty in breathing?
Select Yes No
4. Do you experience any of the following: abdominal pain, vomiting, change in bowel movement, rectal bleeding or bloody / tarry stools?
Select Yes No
5. Do you experience any of the following: Frequent urination , frequent eating, frequent intake of fluids?
Select Yes No
6. For male and female, do you experience any of the following: pain or discomfort on urination, frequency of urination , dribbling of urine, pain during/after sex, blood in the urine, or foul-smelling genital discharge?
Select Yes No
a.) Last Mens Period b.) First Mens Period c.) No. of Pregnancy
8. Do you experience any of the following: Muscle spasm, tremors, weakness, muscle joint pain, stiffness, limitation of movement?
Select Yes No
Symptoms
Diagnosis
Disease (icd10)
Procedure