Emergency Room Admission Form
Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
General Information
Name
First Name
Last Name
ID
Date of birth
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
1
Sex
Feminine
Masculine
Phone Number
Format: (000) 000-0000.
Email
example@example.com
Address
Street Address
City
State / Province
Postal / Zip Code
In case of emergency
Name
Area code
Phone number
Relatioship
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Next
Vital Signs
Heart rate
Blood pressure
Respiratory rate
Temperature
Oxigen saturation
Weight
Height
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Family History
Please fill out
Rows
Mother's side
Father's side
If checked, explain
High blood pressure
2
3
High cholesterol
4
5
Heart disease
6
7
Kidney disease
8
9
Lung disease
10
11
Bleeding disorder
12
13
Cancer
14
15
Diabetes
16
17
Obesity
18
19
Arthritis
20
21
Mental illness
22
23
Alzheimer's/dementia
24
25
Alcoholism
26
27
Other
28
29
Cause of death of grandparents, parents or siblings
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Medical History
Please fill out
Rows
Yes
No
If yes, explain ...........................................................
Stroke
30
31
Heart Disease
32
33
High blood pressure
34
35
Diabetes
36
37
Arthritis
38
39
Seizures
40
41
Mental illness
42
43
Depression
44
45
Kidney disease
46
47
Cancer
48
49
Bleeding disorder
50
51
Alcoholism
52
53
Lung disease
54
55
Tuberculosis
56
57
Anemia
58
59
Obesity
60
61
Stomach Ulcers
62
63
Liver Trouble
64
65
Thyroid Trouble
66
67
AIDS
68
69
Other
70
71
Are you on any medication?
Yes
No
If Yes, list medications
Rows
Dosis
Reason
Is it prescribed?
1
Yes
No
2
Yes
No
3
Yes
No
4
Yes
No
5
Yes
No
Have you had surgery before?
Yes
No
If Yes, explain
Allergies
Rows
Yes
No
If yes, specify
Drugs
72
73
Food
74
75
Latex
76
77
Other
78
79
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Reason for Current Visit
What Is the primary problem?
What are the symptoms?
Have you ever had a similar problem
Yes
No
If Yes, how long ago?
Are there any other problems we should be aware of today?
Yes
No
If Yes, list problems
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Completed by
First Name
Last Name
ID
Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Signature
Submit
Should be Empty: