PHILIPPINES
  [ ] CORD
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A!ministation
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AN%+ROPO(E%RIC (EAS.RE(EN%: Vita& Si*ns: /ei*)t: ______ 0* +ei*)t: ______ -m %em,1: _______ 2C +C: ______ -m CC: ______ -m +R: _______ b,m AC: ______ -m RR: _______ -,m
DR Sta3 Nuse$(i!4ife on Dut#: Li-1 Numbe$E5,i# Date:
Conta-t Numbe: Name of Stu!ent: C&ini-a& Instu-to:
Li-1 Numbe$E5,i# Date: Conta-t Numbe:
De&i'e# Room6NIC.
Conta-t Numbe:
PHILIPPINES
Name of
 __  Name of
 __   __________________________________________________________________________________________ 
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O"S%E%RICAL +IS%ORY: Ga'i!a: ___________ Paa: __________ Abotion: _____________    %#,e of
De&i'e#:
 _________________________________ Gen!e of
E,isiotom#:
 ______________ 
Pesentation: ________________________ Position: ___________    %#,e of P&a-enta& De&i'e#: ______________ %ime of P&a-enta&
De&i'e#:
Obsteti-ian: ______________________________________________ 
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C&ini-a& Instu-to: Li-1 Numbe$E5,i# Date: Conta-t Numbe: De&i'e# Room6NIC.
Su,e'iso: Li-1 Numbe$E5,i# Date: Conta-t Numbe:
CHRIST THE KING COLLEGE 9014 GINGOOG CITY 
PHILIPPINES
RECORD OF S.RGICAL CASES: [ ] SCR." [ ] CIRC.LA%ING
Name of Patient: _________________________________________ Case Numbe: ______________  A*e: ___________ Se5: _______________ Ci'i& Status: ________________   A!!ess:
 __________________________________________________________________________________________  Name of +os,ita&:
 ________________________________________________________________________________   __________________________________________________________________________________________________   __________________________________________________________________________________________________  Post7o,eati'e Dia*nosis:
Anest)esio&o*ist:  %ime of Anest)esia
"e*an:
State!:
En!e!: Date of O,eation: