Hospital Report Sheet
| SAN FRANCISCO RELIEF AND RED CROSS FUNDS INCORPORATED HOSPITAL DEPARTMENT | ||||||||||||||||||||||
| Hospital Report for week ending | 190... | |||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Name of Hospital | ||||||||||||||||||||||
| Superintendent | ||||||||||||||||||||||
| No. | Name of Patient | Age | Single | Mar- ried No. of Chil- dren | Occupa- tion | Address | Society, if any | Admitted | Diagnosis | Condition when Admitted | Discharged | Cost of Main- tenance at $2.00 per day | Remarks | |||||||||
| Be- fore | Af- ter | Be- fore | Af- ter | Day | Hour | Provis- ional when adm’t’d | Con- firmed (date of) | Pulse | Temp. | Resp. | Day | Hour | ||||||||||
| I certify that the above is correct in every detail: | ||||||||||||||||||||||
| (Signed) | ||||||||||||||||||||||
Actual size of sheet 16 x 21 inches.
Above form as illustration