CONTINUE ON BACK WHEN NECESSARY
MEDICAL CERTIFICATE
1. DATE 8A. ALLERGIES 2. TIME AM PM 3. AGE 4. SEX M 8B. WEIGHT F 5. ON ARRIVAL PATIENT WAS: AMBULATORY STRETCHE 8C. TEMPERATURE 8D. PULSE 6. PHONE NUMBER WHEELCHAIR
(
)
7. HOMELESS YES NO
8E. RESPIRATION
8F. B/P
8G. DUE TO INJURY NO YES
9. CURRENT MEDICATIONS
10. TRIAGE
11. SIGNATURE
12. HISTORY AND PHYSICAL
13. DIAGNOSTIC IMPRESSIONS 14. PLAN
15A. ATTENDING OF RECORD
15B. EXMINER'S SIGNATURE
SECTION II - FOR PATIENT
1. DISPOSITION / CLINIC APPOINTMENT 4. CONDITION IMPROVED 2. AFTER CARE SHEET GIVEN 3. FOLLOWUP - ACTIVITY - LIMITATIONS YES NO 5. DATE / TIME OF DISCHARGE 6. SIGNATURE TO INDICATE INSTRUCTIONS GIVEN UNCHANGED 7. PATIENT INSTRUCTIONS
SATISFACTORY
IMPRINT PATIENT DATA CARD
I CERTIFY THAT I RECEIVED AND UNDERSTAND THESE INSTRUCTIONS
VA FORM MAR 1992
8. PATIENT'S SIGNATURE
10-10M
SUPERSEDES VA FORM 10-10M, MAY 1990, WHICH WILL NOT BE USED.
TIME
TEMP
VITAL SIGNS PULSE RESP
B/P
TIME
ORDERS
MD SIGNATURE
TIME
NURSE SIGNATURE
EFFECTIVENESS
CONTINUATION FROM FRONT / PROGRESS NOTE
STUDIES REQUESTED
RESULTS
VA FORM MAR 1992
10-10 M
PAGE 2
SECTION II - FOR PATIENT
1. DISPOSITION / CLINIC APPOINTMENT 4. CONDITION IMPROVED 2. AFTER CARE SHEET GIVEN 3. FOLLOWUP - ACTIVITY - LIMITATIONS YES NO 5. DATE / TIME OF DISCHARGE 6. SIGNATURE TO INDICATE INSTRUCTIONS GIVEN UNCHANGED 7. PATIENT INSTRUCTIONS
SATISFACTORY
IMPRINT PATIENT DATA CARD
I CERTIFY THAT I RECEIVED AND UNDERSTAND THESE INSTRUCTIONS
VA FORM MAR 1992
8. PATIENT'S SIGNATURE
10-10M
PAGE 3 PATIENTS COPY