CHRONOLOGICAL RECORD OF MEDICAL CARE
HEALTH RECORD
DATE
SYMPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION (Sign each entry)
AMIO SCREENING OVERPRINT
Females:
not pregnant
SUBJECTIVE: _____ year old male / female (circle) with a _____ day history of:
blood in stools
pregnant
nausea
vomiting
diarrhea
abdominal pain
fever
rash
open sores / cuts
unknown
cough
dizziness / fainting spells
other symptoms ___________________
no symptoms
Other family members ill:
Recent travel:
Current medications:
OBJECTIVE:
General:
well nourished, well hydrated
moderately ill appearing, mildly dehydrated
non-combative
combative
not alert / not oriented
alert & oriented
Other observations:
ASSESSMENT / PLAN:
Individual is stable, no medical intervention needed
Individual is not stable, medical attention required. Contact medical personnel for assistance.
Additional precautions:
_____________________________
SIGNATURE
RECORDS
PATIENT'S IDENTIFICATION (Use this space for
MAINTAINED
Mechanical Imprint)
AT:
PATIENT'S NAME ( Last, First, Middle initial )
SEX
RANK/GRADE
RELATIONSHIP TO SPONSOR:
STATUS
SPONSOR'S NAME
ORGANIZATION
DEPART./SERVICE
SSN/IDENTIFICATION NO.
DATE OF BIRTH
AMIO SCREENING OVERPRINT
CHRONOLOGICAL RECORD OF MEDICAL CARE
STANDARD FORM 600 (EF)
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