EMERGENCY CARD. about infectious diseases, food, acute professional poisoning, unusual reaction for vaccinations

EMERGENCY CARD

about infectious diseases, food, acute professional poisoning, unusual reaction for vaccinations

1. Diagnosis _____________chicken pox___________________________

approved by the laboratory: yes, no (underline)

2. Surname, name, father´ s name __Alexender Vasilyevich Pavlenko ____

________________________________ 3. Sex ______________male____________

4. Age(for children up to 14 years-date of birth) _________8_______

__________________________________________________________________

5. Address, settlement______Simferopol, Crimea_________ district

street ______Gagarina street___________________ house N __125______ flat N________

______________individual____________________________________________________

(individual, common, communal, write down)

6. Name and place of work(study, children´ s establishment)

____________________Pavlenko school_________________________

__________________________________________________________________

7. Dates of:

disease__________20. 12. 2019________________________________________

consultation(revealed) __________27. 12. 2019___________________

establishment of diagnosis ________________________________________

last attendance to children´ s establishment, school

______________________________________19. 12. 2019____________________________

hospitalization _______________27. 12. 2019_________________

reversible side of form N 058/u

8. Place of hospitalization _______7^th hospital_________________________

9. If poisoning, indicate, where it took place, by which the victim was poisoned__________at home____________________________________

__________________________________________________________________