Tpr Sheet 30656i
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MEDICAL RECORD
VITAL SIGNS RECORD
HOSPITAL DAY DAY
MONTH-YEAR
DAY
19
HOUR
PULSE ( )
TEMP. F ( )
TEMP. C
105
40.6
180
104
40.0
170
103
39.4
160
102
38.9
150
101
38.3
140
100
37.8
130
99
37.2
98.6
36.0
120
98
36.7
110
97
36.1
100
96
35.6
90
95
35.0
(Centigrade Equivalents, for Reference only)
POST-
80
70
60
50
40
Record special data only when so ordered
RESPIRATION RECORD
BLOOD PRESSURE
HEIGHT:
WEIGHT
PATIENT'S IDENTIFICATION
(For typed or written entries give: Name - last, first, middle; rank; rate; hospital or medical facility)
NO.
WARD NO.
VITAL SIGNS RECORD STANDARD FORM 511 (Rev. 9-79) Prescribed by GSA/ICMR FIRMR (41 CFR) 201-45.505
Reset
VITAL SIGNS RECORD
HOSPITAL DAY DAY
MONTH-YEAR
DAY
19
HOUR
PULSE ( )
TEMP. F ( )
TEMP. C
105
40.6
180
104
40.0
170
103
39.4
160
102
38.9
150
101
38.3
140
100
37.8
130
99
37.2
98.6
36.0
120
98
36.7
110
97
36.1
100
96
35.6
90
95
35.0
(Centigrade Equivalents, for Reference only)
POST-
80
70
60
50
40
Record special data only when so ordered
RESPIRATION RECORD
BLOOD PRESSURE
HEIGHT:
WEIGHT
PATIENT'S IDENTIFICATION
(For typed or written entries give: Name - last, first, middle; rank; rate; hospital or medical facility)
NO.
WARD NO.
VITAL SIGNS RECORD STANDARD FORM 511 (Rev. 9-79) Prescribed by GSA/ICMR FIRMR (41 CFR) 201-45.505
Reset
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