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    031 Pre Admission Screening

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    dohtrc pototan
    This document is a pre-admission screening form for a patient being referred to the Department of Health Treatment and Rehabilitation Center in Iloilo, Philippines. It collects information on the patient's symptoms, potential exposure to COVID-19, medical history, current health status, and family health history. The patient attests that the information provided is true and acknowledges the legal and moral implications of providing false information. The form is then signed by the interviewee, interviewer, and admitting physician.

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    © All Rights Reserved
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    031 Pre Admission Screening

    Uploaded by

    dohtrc pototan
    21 views1 page
    This document is a pre-admission screening form for a patient being referred to the Department of Health Treatment and Rehabilitation Center in Iloilo, Philippines. It collects information on the patient's symptoms, potential exposure to COVID-19, medical history, current health status, and family health history. The patient attests that the information provided is true and acknowledges the legal and moral implications of providing false information. The form is then signed by the interviewee, interviewer, and admitting physician.

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    PRE ADMISSION SCREENING FORM

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    This document is a pre-admission screening form for a patient being referred to the Department of Health Treatment and Rehabilitation Center in Iloilo, Philippines. It collects information on the patient's symptoms, potential exposure to COVID-19, medical history, current health status, and family health history. The patient attests that the information provided is true and acknowledges the legal and moral implications of providing false information. The form is then signed by the interviewee, interviewer, and admitting physician.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    21 views1 page

    031 Pre Admission Screening

    Uploaded by

    dohtrc pototan
    This document is a pre-admission screening form for a patient being referred to the Department of Health Treatment and Rehabilitation Center in Iloilo, Philippines. It collects information on the patient's symptoms, potential exposure to COVID-19, medical history, current health status, and family health history. The patient attests that the information provided is true and acknowledges the legal and moral implications of providing false information. The form is then signed by the interviewee, interviewer, and admitting physician.

    Copyright:

    © All Rights Reserved
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    Republic of the Philippines

    DEPARTMENT OF HEALTH TREATMENT AND REHABILITATION CENTER - ILOILO


    Brgy. Rumbang, Pototan, Iloilo
    Tel. No. (033) 529-8955 | e-mail: dohtrcwv@gmail.com

    PRE-ADMISSION SCREENING FORM


    PATIENT: LAST NAME FIRST NAME MIDDLE NAME AGE SEX REFERRED BY

    Has the patient experienced any of the following symptoms during the past 14 days up to the present?
    YES NO SIGNS/SYMPTOMS DATE OF ONSET YES NO SIGNS/SYMPTOMS DATE OF ONSET
    FEVER / FEVERISH LOSS OF APPETITE
    COLDS / RUNNY NOSE MUSCLE ACHES/PAIN
    COUGH WEAKNESS/TIREDNESS
    LOSS OF SMELL OR TASTE NAUSEA OR VOMITING
    HEADACHE DIFFICULTY BREATHING OR
    SORE THROAT SHORTNESS OF BREATH
    DIARRHEA OTHERS, Specify

    Has the patient been in close or direct contact with a suspected/probable/confirmed COVID-19 case?  YES  NO
    Has the patient been in close contact with someone with COVID-19 or influenza-like symptoms?  YES  NO
    Is there a cluster of influenza-like cases or respiratory illnesses in the patient’s current place of
    residence or confinement?  YES  NO
    HEALTH STATUS: BP: _______ PR: _______ RR: _______ TEMP: _______ Weight: _______ Height: _______
    PRE-EXISTING MEDICAL CONDITIONS: YES NO HISTORY OF HOSPITALIZATION:
    Chronic Lung Disease (Asthma, Emphysema, COPD, etc.)
    Respiratory Disease (PTB, Pneumonia, etc.)
    Diabetes Mellitus PRE-EXISTING SURGICAL CONDITIONS:
    Cardiovascular Disease / Hypertension
    Chronic Renal Disease
    Chronic Liver Disease HISTORY OF OPERATION:
    PLHIV (Person Living with HIV or AIDS)
    Immunocompromised (Chronic Steroid Use, Cancer, etc.)
    Neurologic / Neurodevelopmental Disability (Seizures, etc.) HISTORY OF CONSULT/TREATMENT FOR
    OTHERS, Specify PSYCHIATRIC SYMPTOMS/ILLNESS:

    FOOD/DRUG ALLERGIES:
    CURRENT MEDICATIONS (Include Vitamins and Supplements):

    FAMILY HISTORY: Asthma Cancer PTB


    Diabetes Mellitus Hypertension OTHERS, Specify
    I have understood the importance of the questions being asked with regards to my case. I attest that the information given are true
    and to the best of my knowledge. Naintindihan ko ang importansya sang mga palamangkutanon sang medical staff nahanungod sa
    akon sakit. Gina pamatud-an ko nga ang tanan nga ini matuod kag eksakto santo sa akon nahibalu-an.
    I understand the moral and legal implications in disclosing false facts, and withholding information from DOH-TRC Iloilo staff. I am well
    aware of the possible negative consequences of such act to the medical staff, nonmedical personnel, other patients and the rest of the
    community. Nahibaluan ko ang mga legal kag moral nga implikasyon sa paghatag sang sala nga impormasyon. Kon indi ako magsugid
    sang matuod, makahatag ini perwisyo sa mga doctor, nurses, iban nga empleyado sang DOH-TRC Iloilo, iban nga pasyente, kag bilog
    nga miyembro sang komunidad.

    INTERVIEWEE: ______________________________ INTERVIEWED BY: ____________________________________


    SIGNATURE OVER PRINTED NAME SIGNATURE OVER PRINTED NAME

    DOH-TRC Iloilo Physician: _________________________ REMARKS: ______________________________________


    SIGNATURE OVER PRINTED NAME
    FORM-TRCNSO-031 V00 05JAN2021

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