04. Making a Patient Chart

**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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