Name: - _Age/Sex: -
UHID No.: - Occupation: - _
Diagnosis: -
Address: -
Assessment Performa
Personal Information
Chief Complaint: -
History of present illness: -
Past Medical and Surgical History: -
Other conditions : -
TB HTN T2DM
Substance Abuse
Smoking: - Pack Year: -
Alcohol: - _
On Observation
Accessory Muscle Use
Breathing Pattern: - Shallow/ Deep
Intercoastal In Drawing: -
JVP: -
Cyanosis: - Central/Peripheral
