04. Making a Patient Chart

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==== '''Fortunately Where There Is No Doctor includes a form you can copy and print. This is what it looks like but you can print right from the Chapter and page Here.''' ==== .

PATIENT REPORT

TO USE WHEN SENDING FOR MEDICAL HELP



Name of the sick person: __________________________________________

Age: _____

Male ______

Female _______

Where is he (she)? ________________________________

What is the main sickness or problem right now? ________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

When did it begin? __________________________________________________________

How did it begin? ___________________________________________________________

Has the person had the same problem before? ___________

When? _______________

Is there fever? ________

How high? ________

° When and for how long? ___________

Pain? __________

Where? _______________________

What kind?____________________

What is wrong or different from normal in any of the following?

Skin:

____________________________

Ears:

______________________________

Eyes:

__________________________

Mouth and throat:

______________________

Genitals:

__________________________________________________________________

Urine:

Much or little? _______________

Color? ______________

Trouble urinating?_____

Describe: ________________________

Times in 24 hours: _______

Times at night: ____

Stools:

Color? ________________

Blood or mucus? ______________

Diarrhea? ______

Number of times a day: _________

Cramps? ________

Dehydration? _________

Mild or severe? _______________

Worms? __________

What kind? ________________________

Breathing:

Breaths per minute: ___________

Deep, shallow, or normal? ____________

Difficulty breathing (describe):

________________________

Cough (describe):_______

____________________

Wheezing? __________

Mucus? ___________

With blood?_____

Does the person have any of the SIGNS OF DANGEROUS ILLNESS

listed on page 42? __________

Which? (give details) _____________________________________

___________________________________________________________________________

Other signs:

_______________________________________________________________

Is the person taking medicine? __________

What? _______________________________

Has the person ever used medicine that has caused a rash, hives (or bumps)

with itching, or other allergic reactions? ___________

What?_______________________

The state of the sick person is:

Not very serious: ________________

Serious: ________

Very serious: _________________

On the back of this form write any other information you think may be important.

Where There Is No Doctor 2017

You Can print this form right from the PDF of that page or you can modify this form to be more like you want it.
NOTICE there are blanks where you can insert the results of VITAL SIGNS

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© Copyright 2018 by Daniel Blankley. All rights reserved.

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