Scribd
Upload
52 views2 pages

Hears Cho Report Form

This document is a health emergency management services reporting form from the City Health Office of Puerto Princesa City, Philippines. The form collects information about health emergencies, including the type, date, location, and description of the incident. It also collects medical information about any patients, such as their name, age, symptoms, diagnosis, treatment, and disposition. The form is used to report on health emergencies and is prepared, submitted, approved, and noted by various health officials.

Uploaded by

APRIL JOY BENITEZ, MSN, RN
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
52 views2 pages

Hears Cho Report Form

This document is a health emergency management services reporting form from the City Health Office of Puerto Princesa City, Philippines. The form collects information about health emergencies, including the type, date, location, and description of the incident. It also collects medical information about any patients, such as their name, age, symptoms, diagnosis, treatment, and disposition. The form is used to report on health emergencies and is prepared, submitted, approved, and noted by various health officials.

Uploaded by

APRIL JOY BENITEZ, MSN, RN
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 2

Republic of the Philippines

City Government of Puerto Princesa


CITY HEALTH OFFICE
2/F Old City Hall, Brgy. Sta Monica, Puerto Princesa City
Telephone (02) 433-0042; email: [email protected]

HEALTH EMERGENCY MANAGEMENT SERVICES (HEMS)


REPORTING FORM
EVENT/DATE:
A. Event Information (Please Check)
Type of GEOLOGIC WEATHER BIOLOGIC MAN-MADE
Disaster: Poisoning, specify
Volcanic Typhoon Red Tide Epidemic
Eruption Storm Surge Fish Kills Fire Mass Action, specify
Earthquake Drought Locust Explosion
Tsunami Cold Spell Infestation Armed Accident, specify
Landslide Flashflood Conflict
Lahar Terrorism Others, specify

Date of Occurrence: Time of Occurrence: Address where the incident happened


(include Brgy):

Region: IV-B
Municipality/City: Puerto Princesa City
Brief Description of what happened: (How the event happened): Could be Stated in Filipino

Full Name of Patient/s:


Age: Sex: Male Female

Birthday (M-DD-YEAR):

Address:

Chief Complaint: Medical Diagnosis:

Previous History of Illness (if any):

Attending Physician:
Medications (maintenance):
Republic of the Philippines
City Government of Puerto Princesa
CITY HEALTH OFFICE
2/F Old City Hall, Brgy. Sta Monica, Puerto Princesa City
Telephone (02) 433-0042; email: [email protected]

Treatment Given: (Lists all given) Disposition:


 Discharged  Confined  For transfer
Referred

Name of End-Referral Hospital:

REMARKS:

Prepared and Submitted by:

Date Prepared: Mobile No.:


Signature: Landline:
Printed Name: Fax No.:
Designation/Office: Email:

Approved by:

Romwell Raymundo, RN
Assistant DRRM-H Manager

Dr. Mark Haggai Buenaventura


DRRM-H Manager

Noted by:

Ricardo B. Panganiban, MD, RN, RMT


City Health Officer

You might also like