GREGORIO DEL PILAR DISTRICT HOSPITAL
ANIMAL BITE PATIENT'S RECORD
PATIENT'S REGISTRY
-
LAST NAME GIVEN NAME MIDDLE NAME REG. NO.
BIRTHDAY: AGE/SEX:
COMPLETE ADDRESS
CONTACT NO: WEIGHT IN KG:
EXPOSURE HISTORY
DATE OF CONSULTATION: _____________________
DATE OF EXPOSURE: _____________________ WASHING OF BITE ð YES ð NO
PLACE OF ACCURENCE: HOME STREET
PROVINCE STATUS OF BITING ANIMAL:
MUNICIPALITY ð ALIVE
BARANGAY ð KILLED
ANATOMICAL LOCATION ð DEAD DUE TO RABIES
ð FEET ð DEAD TO UNKNOWN REASONS
TYPE OF ANIMAL: ð LEG ð UNKNOWN/ STRAY
ð DOG ð CAT ð KNEE PREVIOUS YES
ð BAT ð MONKEY ð ARMS ANTI- RABIES NOT COMPLETED
ð OTHERS ð HAND VACCINATION COMPLETED WHEN _____________________
ð NECK
ð HEAD
ð OTHERS
DOCTOR'S ORDERS
CATEGORY I CATEGORY II CATEGORY III
ð Feeding/touching an animal nibbling of uncovered skin with or without hematoma transdermal bite/s with BLEEDING
ð Licking of INTACT SKIN MINOR SCRATCH without bleeding/induced to bleed transdermal scratch/es with BLEEDING
ð Exposure to patient with s/sx ABRASION without bleeding/induced to bleed transdermal abrasion/s with BLEEDING
of rabies by sharing of eating (NOTE:anatomical location excluding head,neck minor scratch/es or abrasion/s :
or drinking utensils and genital area) HEAD, NECK, GENITAL AREA
ð Casual contact STATUS OF BITING ANIMAL : Alive MULTIPLE bites/ scratches/abrasions
ingestion of raw infected meat
HISTORY OF PRESENT ILLNESS : unprotected handling of infected carcass
contamination of mucous membranes
PERTINENT PHYSICAL EXAMINATION : Licks on BROKEN SKIN
exposure to BATS
STATUS OF BITING ANIMAL : KILLED, DEAD
DIAGNOSIS : STRAY, UNKNOWN
MANAGEMENT MANAGEMENT MANAGEMENT
washing of bite washing of wound washing of wound
Health Education Health Education Health Education
PRE-EXPOSURE PROPHYLAXIS POST -EXPOSURE Prophylaxis POST -EXPOSURE Prophylaxis
BOOSTER ONLY BOOSTER ONLY
Tetanus Toxoid _____________ Tetanus Toxoid _____________
ATS _____________ ATS _____________
RIG _______________
MEDICATIONS OTHER MANAGEMENT
ð Cloxacillin TID
ð Cefuroxime axetil____________________________BID
ð Mefenamic Acid _____________________________
ð OTHERS: ______________________________
MEDICAL OFFICER
ANNEX B GREGORIO DEL PILAR DISTRICT HOSPITAL
SDN FP M N H C N Referral Form
Referral Category: A1 ( ) A2 ( ) B1 ( ) B2 ( ) C1 ( ) C2 ( ) Unclassified ( )
Date: Time:
REFERRING HEALTH CARE INSTITUTION (HCI)
*Name of HCI: GREGORIO DEL PILAR DISTRICT HOSPITAL *PhilHealth Acc. No.: H03004164
*Address of HCI: Bagio St., Bagumbayan, Bulakan, Bulacan
Contact No.: 792-0119
PATIENT INFORMATION
Name: Bday: Age:
Arrival Date: Arrival Time: No. of hours stayed:
Address: Civil Status:
Type of PhilHealth Membership:
Pre-natal check-up: MD RN RHM PRM No. of Check-ups: BP during pre-natal:
Tetanus Toxoid Given:
Laboratory done: (attach results if available)
CBC Urinalysis HbsAg VDRL Blood Typing Ultrasound Syphillis Screening
Medical History: Hypertension Thyroid Problems Heart Problems Diabetes Mellitus Others: _________
OB History: C/S: ___________ NSD _________
VS: BP: ___________________ HR: _______________ PR: _______________ Blood Type/RH: _______________
PE (answer below)
Head/neck: Heart:
Chest: Abdomen:
FH: _____________________ FHT: ________________________
Pelvis IE: ____________________ Effacement: ____________________ Station: _______________________
BOW ruptured: Yes No Time: _________________________ Character: _____________________
Medication taken (answer below)
Before referral: During transport:
Progress of Labor (attach Partograph)
Diagnosis/es and finding:
Reason/s for referral (specify)
Family Planning Referral: _____ Yes ____ No If Yes, method of choice__________________ Counselled: ___Yes ____No
*Name and designation of referring service provider: *Contact No.:
*Signature of referring provider:
*Accompanied by health worker: ______ Yes _____ No
RETURN SLIP
Date:
18. Patien's Name: Age: Sex:
19. Initial Diagnosis / Admitting Impression:
20. Action Taken: (Admitted, Under Observation, Managed and Discharged, Discharged for Follow-up, Referred to another Facility, etc.)
21. Initial Plan:
(Signature above printed name)
Attending Health Provider / Department/
Facility Contact Number
GREGORIO DEL PILAR DISTRICT HOSPITAL GREGORIO DEL PILAR DISTRICT HOSPITAL
ANIMAL BITE PATIENT'S RECORD ANIMAL BITE PATIENT'S RECORD
PATIENT'S DATA PATIENT'S DATA
- -
LAST NAME GIVEN NAME MIDDLE NAME REG. NO. LAST NAME GIVEN NAME MIDDLE NAME REG. NO.
COMPLETE ADDRESS Birthday Age/sex COMPLETE ADDRESS Birthday Age/sex
Contact Number: Contact Number:
Weight _______ Date Registered _________________ Weight _______ Date Registered _________________
History of exposure History of exposure
Date of Exposure Date of Exposure
Place of Exposure Place of Exposure
Type of exposure Type of exposure
Source of exposure Source of exposure
Category of Exposure Category of Exposure
Post Exposure Prophylaxis Post Exposure Prophylaxis
A. Washing of Bite A. Washing of Bite
B. RIG : B. RIG :
C. Anti - Rabies Vaccine: C. Anti - Rabies Vaccine:
1. Generic Name___________ Brand Name ____________ 1. Generic Name___________ Brand Name __________
2. Route : _______ 2. Route : _______
3. D0 D14 (M) 3. D0 D14 (M)
4. D3 D28/30 4. D3 D28/30
5. D7 ( If dog is not alive after 5. D7 ( If dog is not alive after
14days of observation) 14days of observation)
Status of animal after exposure Status of animal after exposure
Remarks : Remarks :
GREGORIO DEL PILAR DISTRICT HOSPITAL GREGORIO DEL PILAR DISTRICT HOSPITAL
ANIMAL BITE PATIENT'S RECORD ANIMAL BITE PATIENT'S RECORD
PATIENT'S DATA PATIENT'S DATA
- -
LAST NAME GIVEN NAME MIDDLE NAME REG. NO. LAST NAME GIVEN NAME MIDDLE NAME REG. NO.
COMPLETE ADDRESS Birthday Age/sex COMPLETE ADDRESS Birthday Age/sex
Contact Number: Contact Number:
Weight _______ Date Registered _________________ Weight _______ Date Registered _________________
History of exposure History of exposure
Date of Exposure Date of Exposure
Place of Exposure Place of Exposure
Type of exposure Type of exposure
Source of exposure Source of exposure
Category of Exposure Category of Exposure
Post Exposure Prophylaxis Post Exposure Prophylaxis
A. Washing of Bite A. Washing of Bite
B. RIG : B. RIG :
C. Anti - Rabies Vaccine: C. Anti - Rabies Vaccine:
1. Generic Name___________ Brand Name ____________ 1. Generic Name___________ Brand Name __________
2. Route : _______ 2. Route : _______
3. D0 D14 (M) 3. D0 D14 (M)
4. D3 D28/30 4. D3 D28/30
5. D7 ( If dog is not alive after 5. D7 ( If dog is not alive after
14days of observation) 14days of observation)
Status of animal after exposure Status of animal after exposure
Remarks : Remarks :
-
LAST NAME GIVEN NAME MIDDLE NAME REG. NO.
POST-EXPOSURE PROPHYLAXIS
VACCINE TYPE : VERORAB SPEEDA ABHAYRAB VAXIRAB
ROUTE OF ADMINISTRATION : INTRADERMAL INTRAMASCULAR
BOOSTER : YES NO
SCHEDULE OF VACCINATION
DATE DATE GIVEN NAME / SIGNATURE OF STAFF CONSENT
DAY 0
DAY 3
DAY 7
DAY 14
DAY28/3
0
ERIG REFUSED
RIG AMOUN NONE
DATE : SIGNATURE :
T:
PROGRESS NOTES
s ð fever status of biting animal
DATE: ð rashes ð alive
ð numbness at the wound site ð weak
ð headache ð missing
ð others ð change in behavior
O body temperature ______________ ð hydrophobia ð rashes
BP _________; HR_________; ð aerophobia ð others
ð general weakness ð photophobia
A ð s/p animal bite ð others
ð healed wound secondary to animal bite
P ð give day 3 of antirabies vaccine ð cont. observation of biting animal
ð give ERIG ______________________________ð others
ð to come back on DAY 7
s ð fever status of biting animal
DATE: ð rashes ð alive
ð numbness at the wound site ð weak
ð headache ð missing
ð others ð change in behavior
O body temperature ______________ ð hydrophobia ð rashes
BP _________; HR_________; ð aerophobia ð others
ð general weakness ð photophobia
A ð s/p animal bite ð others
ð healed wound secondary to animal bite
P ð give day 7 of antirabies vaccine ð cont. observation of biting animal
ð give ERIG ______________________________ð others
ð to come back on DAY 30
s ð fever status of biting animal
DATE: ð rashes ð alive
ð numbness at the wound site ð weak
ð headache ð missing
ð others ð change in behavior
O body temperature ______________ ð hydrophobia ð rashes
BP _________; HR_________; ð aerophobia ð others
ð general weakness ð photophobia
A ð s/p animal bite ð others
ð healed wound secondary to animal bite
P ð give day 30 of antirabies vaccine ð cont. observation of biting animal
GREGORIO DEL PILAR DISTRICT HOPITAL GREGORIO DEL PILAR DISTRICT HOPITAL
BAGUMBAYAN, BULAKAN BULACAN BAGUMBAYAN, BULAKAN BULACAN
VISITOR'S VISITOR'S
PASS PASS
Male Ward Bed 1 Male Ward Bed 1
GREGORIO DEL PILAR DISTRICT HOPITAL GREGORIO DEL PILAR DISTRICT HOPITAL
BAGUMBAYAN, BULAKAN BULACAN BAGUMBAYAN, BULAKAN BULACAN
VISITOR'S VISITOR'S
PASS PASS
Male Ward Bed 2 Male Ward Bed 2
GREGORIO DEL PILAR DISTRICT HOPITAL GREGORIO DEL PILAR DISTRICT HOPITAL
BAGUMBAYAN, BULAKAN BULACAN BAGUMBAYAN, BULAKAN BULACAN
VISITOR'S VISITOR'S
PASS PASS
Male Ward Bed 3 Male Ward Bed 3
GREGORIO DEL PILAR DISTRICT HOPITAL GREGORIO DEL PILAR DISTRICT HOPITAL
BAGUMBAYAN, BULAKAN BULACAN BAGUMBAYAN, BULAKAN BULACAN
VISITOR'S VISITOR'S
PASS PASS
Male Ward Bed 4 Male Ward Bed 4
GREGORIO DEL PILAR DISTRICT HOPITAL GREGORIO DEL PILAR DISTRICT HOPITAL
BAGUMBAYAN, BULAKAN BULACAN BAGUMBAYAN, BULAKAN BULACAN
VISITOR'S VISITOR'S
PASS PASS
Male Ward Bed 5 Male Ward Bed 5
GREGORIO DEL PILAR DISTRICT HOPITAL GREGORIO DEL PILAR DISTRICT HOPITAL
BAGUMBAYAN, BULAKAN BULACAN BAGUMBAYAN, BULAKAN BULACAN
VISITOR'S VISITOR'S
PASS PASS
Male Ward Bed 6 Male Ward Bed 6
GREGORIO DEL PILAR DISTRICT HOPITAL GREGORIO DEL PILAR DISTRICT HOPITAL
BAGUMBAYAN, BULAKAN BULACAN BAGUMBAYAN, BULAKAN BULACAN
VISITOR'S VISITOR'S
PASS PASS
Male Ward Bed 7 Male Ward Bed 7
GREGORIO DEL PILAR DISTRICT HOPITAL GREGORIO DEL PILAR DISTRICT HOPITAL
BAGUMBAYAN, BULAKAN BULACAN BAGUMBAYAN, BULAKAN BULACAN
VISITOR'S VISITOR'S
PASS PASS
Male Ward Bed 8 Male Ward Bed 8
GREGORIO DEL PILAR DISTRICT HOPITAL GREGORIO DEL PILAR DISTRICT HOPITAL
BAGUMBAYAN, BULAKAN BULACAN BAGUMBAYAN, BULAKAN BULACAN
VISITOR'S VISITOR'S
PASS PASS
Female Ward Bed 1 Female Ward Bed 1
GREGORIO DEL PILAR DISTRICT HOPITAL GREGORIO DEL PILAR DISTRICT HOPITAL
BAGUMBAYAN, BULAKAN BULACAN BAGUMBAYAN, BULAKAN BULACAN
VISITOR'S VISITOR'S
PASS PASS
Female Ward Bed 2 Female Ward Bed 2
GREGORIO DEL PILAR DISTRICT HOPITAL GREGORIO DEL PILAR DISTRICT HOPITAL
BAGUMBAYAN, BULAKAN BULACAN BAGUMBAYAN, BULAKAN BULACAN
VISITOR'S VISITOR'S
PASS PASS
Female Ward Bed 3 Female Ward Bed 3
GREGORIO DEL PILAR DISTRICT HOPITAL GREGORIO DEL PILAR DISTRICT HOPITAL
BAGUMBAYAN, BULAKAN BULACAN BAGUMBAYAN, BULAKAN BULACAN
VISITOR'S VISITOR'S
PASS PASS
Female Ward Bed 4 Female Ward Bed 4
GREGORIO DEL PILAR DISTRICT HOPITAL GREGORIO DEL PILAR DISTRICT HOPITAL
BAGUMBAYAN, BULAKAN BULACAN BAGUMBAYAN, BULAKAN BULACAN
VISITOR'S VISITOR'S
PASS PASS
Female Ward Bed 5 Female Ward Bed 5
GREGORIO DEL PILAR DISTRICT HOPITAL GREGORIO DEL PILAR DISTRICT HOPITAL
BAGUMBAYAN, BULAKAN BULACAN BAGUMBAYAN, BULAKAN BULACAN
VISITOR'S VISITOR'S
PASS PASS
Female Ward Bed 6 Female Ward Bed 6
GREGORIO DEL PILAR DISTRICT HOPITAL GREGORIO DEL PILAR DISTRICT HOPITAL
BAGUMBAYAN, BULAKAN BULACAN BAGUMBAYAN, BULAKAN BULACAN
VISITOR'S VISITOR'S
PASS PASS
Female Ward Bed 7 Female Ward Bed 7
GREGORIO DEL PILAR DISTRICT HOPITAL GREGORIO DEL PILAR DISTRICT HOPITAL
BAGUMBAYAN, BULAKAN BULACAN BAGUMBAYAN, BULAKAN BULACAN
VISITOR'S VISITOR'S
PASS PASS
Female Ward Bed 8 Female Ward Bed 8
GREGORIO DEL PILAR DISTRICT HOPITAL GREGORIO DEL PILAR DISTRICT HOPITAL
BAGUMBAYAN, BULAKAN BULACAN BAGUMBAYAN, BULAKAN BULACAN
VISITOR'S VISITOR'S
PASS PASS
Pedia Ward Bed 1 Pedia Ward Bed 1
GREGORIO DEL PILAR DISTRICT HOPITAL GREGORIO DEL PILAR DISTRICT HOPITAL
BAGUMBAYAN, BULAKAN BULACAN BAGUMBAYAN, BULAKAN BULACAN
VISITOR'S VISITOR'S
PASS PASS
Pedia Ward Bed 2 Pedia Ward Bed 2
GREGORIO DEL PILAR DISTRICT HOPITAL GREGORIO DEL PILAR DISTRICT HOPITAL
BAGUMBAYAN, BULAKAN BULACAN BAGUMBAYAN, BULAKAN BULACAN
VISITOR'S VISITOR'S
PASS PASS
Pedia Ward Bed 3 Pedia Ward Bed 3
GREGORIO DEL PILAR DISTRICT HOPITAL GREGORIO DEL PILAR DISTRICT HOPITAL
BAGUMBAYAN, BULAKAN BULACAN BAGUMBAYAN, BULAKAN BULACAN
VISITOR'S VISITOR'S
PASS PASS
Pedia Ward Bed 4 Pedia Ward Bed 4
GREGORIO DEL PILAR DISTRICT HOPITAL GREGORIO DEL PILAR DISTRICT HOPITAL
BAGUMBAYAN, BULAKAN BULACAN BAGUMBAYAN, BULAKAN BULACAN
VISITOR'S VISITOR'S
PASS PASS
Pedia Ward Bed 5 Pedia Ward Bed 5
GREGORIO DEL PILAR DISTRICT HOPITAL GREGORIO DEL PILAR DISTRICT HOPITAL
BAGUMBAYAN, BULAKAN BULACAN BAGUMBAYAN, BULAKAN BULACAN
VISITOR'S VISITOR'S
PASS PASS
Pedia Ward Bed 6 Pedia Ward Bed 6
GREGORIO DEL PILAR DISTRICT HOPITAL GREGORIO DEL PILAR DISTRICT HOPITAL
BAGUMBAYAN, BULAKAN BULACAN BAGUMBAYAN, BULAKAN BULACAN
VISITOR'S VISITOR'S
PASS PASS
Pedia Ward Bed 7 Pedia Ward Bed 7
GREGORIO DEL PILAR DISTRICT HOPITAL GREGORIO DEL PILAR DISTRICT HOPITAL
BAGUMBAYAN, BULAKAN BULACAN BAGUMBAYAN, BULAKAN BULACAN
VISITOR'S VISITOR'S
PASS PASS
Pedia Ward Bed 8 Pedia Ward Bed 8
GREGORIO DEL PILAR DISTRICT HOPITAL GREGORIO DEL PILAR DISTRICT HOPITAL
BAGUMBAYAN, BULAKAN BULACAN BAGUMBAYAN, BULAKAN BULACAN
VISITOR'S VISITOR'S
PASS PASS
Pedia Teens Bed 1 Pedia Teens Bed 1
GREGORIO DEL PILAR DISTRICT HOPITAL GREGORIO DEL PILAR DISTRICT HOPITAL
BAGUMBAYAN, BULAKAN BULACAN BAGUMBAYAN, BULAKAN BULACAN
VISITOR'S VISITOR'S
PASS PASS
Pedia Teens Bed 2 Pedia Teens Bed 2
GREGORIO DEL PILAR DISTRICT HOPITAL GREGORIO DEL PILAR DISTRICT HOPITAL
BAGUMBAYAN, BULAKAN BULACAN BAGUMBAYAN, BULAKAN BULACAN
VISITOR'S VISITOR'S
PASS PASS
Pedia Teens Bed 3 Pedia Teens Bed 3
GREGORIO DEL PILAR DISTRICT HOPITAL GREGORIO DEL PILAR DISTRICT HOPITAL
BAGUMBAYAN, BULAKAN BULACAN BAGUMBAYAN, BULAKAN BULACAN
VISITOR'S VISITOR'S
PASS PASS
Pedia Teens Bed 4 Pedia Teens Bed 4
GREGORIO DEL PILAR DISTRICT HOPITAL GREGORIO DEL PILAR DISTRICT HOPITAL
BAGUMBAYAN, BULAKAN BULACAN BAGUMBAYAN, BULAKAN BULACAN
VISITOR'S VISITOR'S
PASS PASS
Pedia Teens Bed 5 Pedia Teens Bed 5
GREGORIO DEL PILAR DISTRICT HOPITAL GREGORIO DEL PILAR DISTRICT HOPITAL
BAGUMBAYAN, BULAKAN BULACAN BAGUMBAYAN, BULAKAN BULACAN
VISITOR'S VISITOR'S
PASS PASS
Pedia Teens Bed 6 Pedia Teens Bed 6
GREGORIO DEL PILAR DISTRICT HOPITAL GREGORIO DEL PILAR DISTRICT HOPITAL
BAGUMBAYAN, BULAKAN BULACAN BAGUMBAYAN, BULAKAN BULACAN
VISITOR'S VISITOR'S
PASS PASS
Pedia Teens Bed 7 Pedia Teens Bed 7
GREGORIO DEL PILAR DISTRICT HOPITAL GREGORIO DEL PILAR DISTRICT HOPITAL
BAGUMBAYAN, BULAKAN BULACAN BAGUMBAYAN, BULAKAN BULACAN
VISITOR'S VISITOR'S
PASS PASS
Pedia Teens Bed 8 Pedia Teens Bed 8
GREGORIO DEL PILAR DISTRICT HOPITAL GREGORIO DEL PILAR DISTRICT HOPITAL
BAGUMBAYAN, BULAKAN BULACAN BAGUMBAYAN, BULAKAN BULACAN
VISITOR'S VISITOR'S
PASS PASS
Surgery Ward Bed 1 Surgery Ward Bed 1
GREGORIO DEL PILAR DISTRICT HOPITAL GREGORIO DEL PILAR DISTRICT HOPITAL
BAGUMBAYAN, BULAKAN BULACAN BAGUMBAYAN, BULAKAN BULACAN
VISITOR'S VISITOR'S
PASS PASS
Surgery Ward Bed 2 Surgery Ward Bed 2
GREGORIO DEL PILAR DISTRICT HOPITAL GREGORIO DEL PILAR DISTRICT HOPITAL
BAGUMBAYAN, BULAKAN BULACAN BAGUMBAYAN, BULAKAN BULACAN
VISITOR'S VISITOR'S
PASS PASS
Surgery Ward Bed 3 Surgery Ward Bed 3
GREGORIO DEL PILAR DISTRICT HOPITAL GREGORIO DEL PILAR DISTRICT HOPITAL
BAGUMBAYAN, BULAKAN BULACAN BAGUMBAYAN, BULAKAN BULACAN
VISITOR'S VISITOR'S
PASS PASS
Surgery Ward Bed 4 Surgery Ward Bed 4
GREGORIO DEL PILAR DISTRICT HOPITAL GREGORIO DEL PILAR DISTRICT HOPITAL
BAGUMBAYAN, BULAKAN BULACAN BAGUMBAYAN, BULAKAN BULACAN
VISITOR'S VISITOR'S
PASS PASS
Surgery Ward Bed 5 Surgery Ward Bed 5
GREGORIO DEL PILAR DISTRICT HOPITAL GREGORIO DEL PILAR DISTRICT HOPITAL
BAGUMBAYAN, BULAKAN BULACAN BAGUMBAYAN, BULAKAN BULACAN
VISITOR'S VISITOR'S
PASS PASS
OB -CS Ward Bed 1 OB -CS Ward Bed 1
GREGORIO DEL PILAR DISTRICT HOPITAL GREGORIO DEL PILAR DISTRICT HOPITAL
BAGUMBAYAN, BULAKAN BULACAN BAGUMBAYAN, BULAKAN BULACAN
VISITOR'S VISITOR'S
PASS PASS
OB -CS Ward Bed 2 OB -CS Ward Bed 2
GREGORIO DEL PILAR DISTRICT HOPITAL GREGORIO DEL PILAR DISTRICT HOPITAL
BAGUMBAYAN, BULAKAN BULACAN BAGUMBAYAN, BULAKAN BULACAN
VISITOR'S VISITOR'S
PASS PASS
OB -CS Ward Bed 3 OB -CS Ward Bed 3
