Patient Data Collection Form
NOMBOR ENTRI AKAN DIJANA SECARA AUTOMATIK.
TARIKH KES:
NAMA:
NO PENDAFTARAN/PENGENALAN/PASSPORT:
UMUR:
JANTINA:
Lelaki
Perempuan
BANGSA:
Choose
MELAYU
CINA
INDIA
OTHER
Please Specify Race:
LOKASI:
Choose
KOMERSIAL
KEDIAMAN
PUSAT PENDIDIKAN
PUSAT KESIHATAN
JALAN
AWAM
OTHER
Please Specify Location:
PAST MEDICAL HISTORY
+ Add Medical Condition
PAST SURGICAL HISTORY
+ Add Surgical History
ALLERGY HISTORY
+ Add Allergy Condition
ADUAN UTAMA:
Choose
BODY WEAKNESS
CHEST PAIN
FAINTED
PALPITATION
SHORTNESS OF BREATHING
SWEATING
VERTIGO
DIZZINESS
GIDDINESS
GCS:
Choose
3
4
5
6
7
8
9
10
11
12
13
14
15
TEKANAN DARAH SYSTOLIC
(mmHg)
TEKANAN DARAH DIASTOLIC
(mmHg)
PULSE RATE
(bpm)
RESPIRATION RATE
(RPM)
OXYGEN SATURATION
(%)
TEMPERATURE
(°C)
PHYSICAL EXAMINATION:
PAIN SCORE:
0
1
2
3
4
5
6
7
8
9
10
ECG FINDINGS:
None
Sinus Rhythm
ST Elevation
ST Depression
LBBB
RBBB
1st Degree Heart Block
2nd Degree Heart Block
Ventricular Tachycardia
Supraventricular Tachycardia
Pulseless Ventricular Tachycardia
Ventricular Fibrillation
Pulseless Electrical Activity
Asystole
Other
Please Specify ECG Finding:
TRIAGE:
Choose
RED
YELLOW
GREEN
PHC DIAGNOSIS:
ED DIAGNOSIS:
FINAL DIAGNOSIS:
