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PROVIDENCE ANIMAL BITE & MEDICAL CLINIC

San Fabian, Pangasinan
ANIMAL BITE CONSULTATION SHEET
PATIENT DETAILS
Name: CRUZ, EMA IC: Date:
Guardian's Name: Age: Gender: Occupation:
Address: Contact No:
EXPOSURE
Date of Exposure: Place of Exposure: Type of Animal:
Ownership: Can animal be observed for 14 days? Animal Status:
Animal Behavior & Incident Description:
Behavior Before Bite:
Behavior During Bite:
Behavior After Bite:
Additional Incident Details (Optional):
Exposure Site:
Was the skin broken? Did the wound bleed spontaneously? Other Complaint:
PAST MEDICAL HISTORY EXAMINATION
Co-morbid: Drug Allergy:
BP
PR
RR
T
WT
Exposure Wound Category:
Other Medical Condition / Treatment:
Vaccination History Against Rabies: Tetanus Status:
DOCTOR ASSESSMENT
Physical Examination: Assessment: Diagnosis:
DOCTOR'S ORDERS
Orders:
Rabies Vaccine Regimen:
ERIG Plan: ERIG Dose & Route:
mL
mL
Enter the actual ERIG amount for each route. Either or both routes may be used.
ATS Dose: TT Dose:
Medications: 		Plan: Referral Plan: Follow-up Date: Doctor:
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Remarks / Other Plan:
TREATMENT COUNSELING / PATIENT DECISION
Treatment Status: Refused Treatment: Reason for Refusal:
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