n Unique Patient Number:n n Date Admitted:n n

n First Name:n n Middle Name:n n Last Name:n n Gender:n n–Select–nMalenFemalenOthern n Date of Birth:n n

n Purok or Street:n n Barangay:n n City / Municipality:n n Province:n n Zip Code:n n

n Signs and Symptoms:n n Types of Laboratories Performed:n n Diagnosis:n n Attending Physician:n n