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Referral 11

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jollie gallardo
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58 views2 pages

Referral 11

Uploaded by

jollie gallardo
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as XLSX, PDF, TXT or read online on Scribd
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Republic of the Philippines

Province of Surigao del Sur


CIYT HEALTH UNIT & FAMILY PLANNING CENTER

OFFICE OF THE CITY HEALTH OFFICER

CLINICAL REFERRAL SLIP

Date: ___________ Conducting Person: _____________________


Name of Patient: ________________________________Age: ______ Sex: _______ Status: ___
Birthday:_______________________________ Transient Address: ______________________________
Permanent Address: ______________________________________________________________________
Spouse:_________________________________Mother: _________________________________________
Father: __________________________________________
Chief PE Findings: ________________________________________________________________________
_______________________________________________________________________

BP = _________ HR = _________ RR = __________ WT = _________ Temp.: _________


Pertinent PE Findings: ____________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________

Assessment/Impression: __________________________________________________________________
________________________________________________________________________________________

Action Taken: ____________________________________________________________________________


__________________________________________________________________________________________________
Reason for Referral: ______________________________________________________________________
Referred to: ______________________________________________________________________________

Status of Patient upon Arrival: ___________________________________________________________

Received by: _____________________________________________________________________________

Time Received: ___________________________________________________________________________

Date Received: ___________________________________________________________________________

RETURN SLIP
Date: ___________________
Referred by :_________________________________________________________________________
Name of Patient :_________________________________________________________________________
Status :_________________________________________________________________________
Initial Action Ta :_________________________________________________________________________
Admitting Officer
:___________________________________________________________________________

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