EnsoMed

In-Patient/Service Inquiry

From Date

To Date

Incharge Doctor

Patient Name

Patient ID	Patient Name	Date Admitted	Service Area	Doctor In-Charge	Status

Pre-Appointment Screening Questionnaire.

Patient Information
Search Item 1

Patient ID:		Patient Name:

Triage/FPE Date

Questionnaire
NO QUESTIONNAIRE TO DISPLAY

Patient Information
Search Item 1

Patient ID:		Patient Name:

Assessment Date

NCD Questionnaire
NO QUESTIONNAIRE TO DISPLAY

Patient Name:
Diagnosis:
Complaint:
Remarks:

Other Diagnosis:

Reason for Admission

History of Present Illness

Pertinent Past Medical History

Medical History

Vitals

Date Time	Height	Weight	Blood Pressure	Temparature	Pulse Rate	Heart Rate	Respiratory Rate

Signs & Symptoms

Management

Doctor's Action

Prescriptions

Lab Works

Date Time	Test Name	Description	Remarks
NO LAB WORKS TO DISPLAY

Triage Assessment History

Date Time	Category	Questions	Answers
NO TRIAGE HISTORY TO DISPLAY

NCD Assessment History

Date	Questions	Answers
NO NCD HISTORY TO DISPLAY

Patient Information
Search Item 1

Patient ID:		Patient Name:

Assessment Date

NCD Questionnaire
NO QUESTIONNAIRE TO DISPLAY

Date

Lab Work

Is Physician's Recommendation

Yes

Remarks

Referral Facility

Patient Remarks

Attachment

Lab Tests:

Name	Result	Range

Last Name
First Name
Middle Name
Birthday
Gender
Blood Group

Address 1
City
Mobile No.
Email Address

Category
Name
Days
Qty
Instruction

Date
Time
Pulse Rate	/min
Blood Pressure	mm of Hg
Temperature	C
Heart Rate	bpm
Respiratory Rate	bpm
Height	Cm
Weight	Kg

EnsoMedEnterprise

In-Patient/Service Inquiry