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YHCA GNOTOB ABACA
Student #: 2024-09134
Consultation Information
Consultation Date & Time *
Reason for Consultation *
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Fever
Cough/Cold
Stomachache
Headache
Injury
Allergic Reaction
Breathing Difficulty
Other
Vital Signs
Temperature
°C
Height
cm
Weight
kg
Blood Pressure
mmHg
Pulse Rate
bpm
Assessment
Symptoms/Complaints *
Diagnosis
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Flu
Common Cold
Migraine
Gastroenteritis
Fracture/Sprain
Allergic Reaction
Skin Rash
Other
Treatment
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Rest in Clinic
First Aid
Over-the-Counter Medication
Prescribed Medication
Referral to Parent/Guardian
Referral to Specialist
Other
Medications & Notes
Prescribed Medication
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Paracetamol
Ibuprofen
Antihistamine
Antibiotics
Other
Hospital Referred
No referral needed
Parent/Guardian
Hospital
Specialist
Counselor
Other
Allergies/Notes
Additional Notes
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