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.wiiHBeau.
f l L ' 2 . 1 0 1 O S
h o s p i t m l
Pasientno. Patient’s No.
M VF
TPH 3
Oud.Age..
Indeling Classification.
Datum Date...........R o . i J i
Voorlopige diagnose ( C\ \ ft Provisional diagnosis.................................
Handtekening van geneesheer (indien beskikbaar) Doctor's signature (if available)...................................
ONTSLAG
Datum van ontslag Date of discharge.,
Finale diagnose . / ' Final diagnosis...................
Handtekening van geneesheer Doctor's signature......................
TREATMENTHOSPITAALBEHANDELING GEWEIER • REFUSED HO:
-hospitaal op my eie verantwoordelikheid Hospital on my own responsibility andEk, die ondergetekende, verlaat die
I, the undersigned, leave the./..................................
en strydig met die advies van die behandelende geneesheer. against the advice of the attending doctor.
Handtekening van pasient Signature of patient...........Getuies 1
WitnessesDatum D a te ...
uitdiej... .out of thei Ek, die ondergetekende, neem die pasient
i I, the undersigned, take the patient........ ....
-hospitaal op my eie verantwoordelikheid en strydig met die Hospital on my own responsibility and against the advice of
advies van die behandelende geneesheer. the attending doctor.
Handtekening Signature ......
Getuies Witnesses 1
Hoedanigheid Capacity........
DatumDate..;
Vir besonderhede van behandeling gebruik vorm T.P.H. 3 (a) For particulars of treatment use from T.P.H. 3(a)
Geneesheer • Doctor
A D D R E S S O G R A P HFoonPhone.................................................
OPNEMING • ADMISSION
A . o o
Q.P.-S. 042-0236 TPH 3 (b)
PROGRESS NOTE • VORDERINGVERSLAGHOSPITAL WARD DATE ADMITTED
.................................................... HOSPITAAL SA A L................ DATUM TOEGELAAT..................................
PATIENT • PASIENT PATIENT’S No. • PASIENT No. AGE • OUDERDOM
DateDatum Progress notes • Vorderingverslae Investigations & results
Ondersoeke & uitlsae
- t
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• P i n ( 4 y • r i
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Please turn over • Blaai asseblief om
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c-c^—
A i C r o
•T.P.H . 172
DATEDATUM
DETAILS OF PRESCRIPTION VOORSKR1F BESONDERHEDE
QTY.HOEV.
PHARMACISTAPTEKER
r /k ’ /k . T r f ̂ o r
.-.1. . . <£"' / W / f / ? - / U - ' U , U2f eKwivalentequivalent
y ^ of ekwivalentii or equivalentti of ekwivalentI
or equivalent* of ekwivalent
or equivalent /
■ ■ of ekwivalent
or equivalenti
...... . | of ekwivalentl, i - - * or equivalent
; : " of ekwivalent
or equivalent.\
.. • of ekwivalent
jV . , ___ ____ w “ or' equivalentM . ' “ '■ ' r\ __of ekwivalent * -i ̂t .... •• or equivalent »
1\ .... :;u - :■ ” " • • of ekwivalent i »• i
• _ ___...... .. ... or equivalent,,■ of ekwivalenti
. .. ,
> ̂ or equivalent • V . .. V . 4
■ i "W ' of ekwivalent
or equivalent
• ” .x - —of ekwivalent
* . or equivalent
%G.P.-S. 042-0186..• -'T .«*&*•, • » L
m -fSlfef.;,! r ' v' r iV 'w . f '
MEDICINE ADMINISTRATION SHEET • MEDISYNETOEDIENINGVORM T P H 1 5 2 M
Sheet No. o( Vel.No...................................... van.,
7 / f b ‘ 7 ^ ^ 4/
--- / / ! y -Year,* Jaar
•-! / JMonth • Maand ; j -Hfj-i: Hospital • Hospltaal W .D . • A .F .D . N a m e • N a a m N u m b e r • N o m m e r A g e • O u d . D o c t o r • G e n e e s h e e r i C la s s i f i c a t i o n • In d e lin g
t j L J O
G.P.-S. 042-0174
24 UURLIKSE VOGBALANSKAART HOURLY FLUID BALANCE CHART
Algemene Inligting • General InformationKoppie • Cup 150Glas • Tumbler 200Voedingsbeker • Feeding Cup 200Sopbakkie • Soup bowl 220Kraffie • Carafe 600
m£
Naan, . Name: A & K A j
Reg. No.: o p
Saal • Ward:
T.P.H. 118
Datum • Date:
Inst
ruks
les
Inst
ruct
ions
Intraveneua • Intravenous Vervang • Replaced Oraal/NasogastriesOral/Nasogastric
No. Tipe en volume • Type and volume d/min Tyd • Time Deur • By
Akkumulatiewe vogbalans • Accumulative fluid balance
tnname • Intake Ultskeidlng • Output
HandtekeningSignature
Intravenous Oraal/Nasogastries Intravenous Oral/Nasogastric
UrineNaso-
gastriesNasogastric
Drei-neringDrainage
BrakingDiaree
VomitusDiarrhoea
S.G.No. Tipe • Type Volume
(mf) Tipe • Type Volume(mf)
0007
0008
0009
0010
0011
0012
0013
0014
0015
0016
0017
0018SubtotaaJ Sub Total
0019
0020
0021 J h c k l b - /o o c tu .'k
0022
/ X J00
2300
2400
0100
0200
0300
04
0005 £ K & Q v
0006 1 r vSubtotaal Sub Total
Totaal • Total ^ wBalansBalance
Totale inname • Total intake Totale uitskeiding • Total output
A
(C O
OPNAMEDAG • DAY OF ADMISSION: OPERASIEDAG • DAY OF OPERATION:
KONTPOLEKAART CONTROL CHART
TPH 117
NAAM • NAME: A/^S M e ? /
REG. No.: 7 f f ^ S A A L • WARD:
DOKTER • DOCTOR: / ^
Siektedag • Day of illness
DATUM • DATE IQ _TYD • TIME
TEMPERATUURTEMPERATURE
40
395
39
385
38
375
37
365
36
~ — r
POLS • PULSE <2C oASEMHALINGRESPIRATION
BLOEDDRUK BLOOD PRESSURE
200
180
160
140
120
100
80
60
40
STOELGANG • STOOLS
S.G.
KLEUR • COLOUR
REUK • ODOUR
AFSAKSELS • SEDIMENT
Ph < rALBUMIEN • ALBUMIN
BLOED • BLOOD
GLUKOSE • GLUCOSE N / hKETONE • KETONES h / n l.MASSA • MASS
HandtekeningSignature f f l c u t z
G.P.-S. 042-0213
IN C m a A G EA DM ISSIO N FORM T .P .H . 1
_________________________. i d e / j t i t y N O .
Hospital
D A T ! O F A Q M IS31Q N
SURNAME £-
CHRISTIAN NAMES RESIDENTIAL ADDRESS— UNE-1 C LASSIFIC ATIO N
O A T t O F R E C L A S S IF IC A T IO N
Date of B irth Race M a r ita l sta te
C hu rch C on g re ga tio nM a lden N am e M in is te r
N am e and A ddress o f E m p lo y e r
.e lephone N o . (H om e) T e le p h o n e N o .(W o rk )O c c u p a tio n /R a n k . . .
N am e o f n e x t o f K in ^tionsh ip
R es iden tia l A ddress
T^lephone No,
R eferred to h o sp ita l b y / f r o mNam e o f fa m ily d o c to r
A C C ID EN TIn case o f a cc iden t or ----------- ;—Ir^ u ry , s ta te ^ <
Reg. n um b e r o f veh ic le used to
Place
Roadacc iden t
p a t ie n t to h o sp ita ln s p o r
O th e rReason
A tte m p te dS u ic id e A ssa u ltIllnessREASON FOR ADM ISSIO N
U n b o o k e d CaseSOURCE OF A D M IS S IO N * B o o k e d Case |___|
Ex O u t-P a tie n ts : O w n H o s p ita l £
D e p a rtm e n t A d m it te d t o : M e d ic a l [
O th e r H osp ita l E x C a sa u lty : O w n H osp ita l
S urgery ynaeco logy and O b s te tr ics
N am e and Address o f F rie n d
T e le p h o n e no.
A U TH O R ITY / IN ST ITU TIO N P O S S IB L Y R E S P O N S IB LE FOR H O S P IT A L C H A R G E S
IN ITIALSSU R N A M E / IN ST ITU TIO N
• M E O f S T R E E T Z -* .0 . BOX AN D N U M B ER
C IT Y / TO W NS U B U R B
N AM E O F S IC K FUN D / M EO ICA L A ID SO C IE TY AN D M E M B E R S H IP N U M B ERPO STA L CODE
PARTICULARS OF PERSON RESPONSIBLE FOR PAYMENT OF THE ACCOUNT
Surname ....... ....TT...L./.7.../...
Postal Address ............. .....
Residential Address ........ :.............. .
i.d . N o . .....v........
Other Particulars (eg P.F. Number)
Name and address of employer ....,
Christian Names
Resident Permit/Passport No.
; . . . . . . . r.. . Occupation
F u ll name o f younges t c h ild a t sch oo l age
N am e o f schoo l w h ic h he /she a tte n d s
P A R T IC U L A R S FO R C LA S S IF IC A TIO N
N U M B E R O F PER SO N S*fN H O U S E H O L D (B re a d w in n e r end de-pendants e xc lu d in g m in o r c h iId /e n o< 16 y e a r* and o ld e r w h o are - V ----- 3̂ .se lf-sup p o rting ) j * .A N N U A L GROSS IN C O M E O F F A M IL Y b y w a y o f sa lary and a llow ances, bonus, com m isson, re n t d iv idends , e tc ., a n d /o r n e t t in c o m e b y w a y o f fa rm in g , tra d e , in d u s try o r any business.
’.(E x c lu d in g Incom e in respect o f i Vm in o r c h ild re n o f .16 years a nd o ld e r w h o are s e l f - s u p p o r t i n g ) . ^
M o n th /W e e k
T o ta l fa m ily in c o m e
I hereby c e r t i fy th a t th e 'a b o v e -m e n tio n e d p a r t ic u la r^ iu i by me are to the best o f m y k n o w le d g e tru e and c o /re d t. S igna tu re :
s ia te : In it ia ls and S un
A d d re s s
Cash RecCheckedbyFOR OFFLCEAiSS: r
C la ss if ie d ,t/o n B n i f i W i f f x>n A lim is s io nR e c e ip t n o . D a t e V . Q . . '
Mark applicable box w ith XP L E A S E SEE O V E R L E A F FO R F U R T H E R A D D IT IO N A L P A R T IC U L A R S
A D M IS S IO N FO RM T .P .H .1
( T \ £ /H ospital.........................................................................
n
M l h W 7A . E gA . C O
P«- IN C H A W O E ^
I / I I I
IO E R T IT Y N O .
1 L a___l
SURNAME
CHFUSTIAN NAMES RESIDENTIAL ADDRESS— UNE-1
-2
-3
D a te o f B irth
3 r / | i fJ____ I------- L ___ I____ I -
A W &' • i i t i____ I—
_I____ L -1____ L J ____ L.
11 i i i _____i------ i— L 2------1— -I------1------1------ 1------ 1 i . - ------ ! _ J ------1— -L .( b % V O - , ; 3 r - . r S . - ' r . - ^ - . /
i I . . i ‘ I 1 » ‘ I - I - l » i - t - I - ' i — t____1------- 1------_L_
7 o ' 7- y i 3 5 A q g-HT ^ 1? T 3 > n,MO i i i i i i ■------- 1------- 1-------1-------1------- 1____ i—
7 «aa<t> X i o n gi____ i____ i i ___ i____ L-
i ---------------- 1---- -----------------r - 1------- -—j — Sex | MT-j F | "R a c e
i . i___ L i . I 1— —1 -1--------o p M a rita l s ta te M
WARD NQ^’ O Y 'j ____L
O ^ T « o r A O M IS S IO N
T j
CLASSIFICATION
R ECLASSIFICATION
r p nJ___L
D A T * O F R E C L A S S I F I C A T I O N
J ____LA ge in Years &
C o n g re g a tio n ..................................M in is te r
N am e end A ddresso f E m p lo y e r . - — f
_ _ ■ a-3 y r " - - o 9 ^O c c u p a tio n /R a n k ..................................................................................................................................................................... ..............■ - T e lep h o ne N o . Work)
N am e o f n e x t o f K in .................................................................
R es id e n tia l A dd ress . ............: ............( ^ f - f
H usband W ife Guardian
...................................................................................... ............. / } • * • • ®C.ePh One No
N am e o f fa m ily d o c to r .................................................................................................. R eferred to h o s p ita l b y / f ro m
. D> r i T IM E In ju ry on d u ty *
oc\Road
a c c id e n t*
r f u ../ l....^T eC .ephone N o .................................................... £ . . . .
..............
•iciDENT''rh case o f a cc id e n t o r ir ^ u ry , s ta te
Reg. n u m b e r o f v e h ic le used to tra n s p o r t p a t ie n t to h o sp ita l
Place
^ W . < „
XREASON FOR A D M IS S IO N * Q lniurY - S u !c S e 'e d [ Z ] A iS aU lt Q P o ison ing Q ° ; h3" n Q
SOURCE OF A D M IS S IO N ' B o o ked Case | j U n b o o k e d Case [ j P riva te /M e d ica l A id D o c to r | { T ransfe rred □
Ex Out-Patients: O w n H o sp ita l ...|~~ ] O th e r H o sp ita l | | Ex C asa u lty : O w n H o s p ita lf " ^ ^ O th e r H osp ita l □
D e p a r t m e n t Adm itted to : M e d ica l [ j S u rge ry p — •j-T g yn ae co l.o gy and O b s te trics I I
N am e and A ddress o f F r ie n d .... ......................................... #* .......................... .................................. T e lephone no.:
A U TH O R ITY m n s h t u T io n p o s s i b l y r e s p o n s i b l e f o r H O SP ITA L C H A R G ES
SU R N A M E / IN STITU TIO N
J ____ L i i i i i i i r i
-jQ z kS T R E E T V ^ O . B O X ANO N U M B ER
I I I i I I i____ L I I I____ I____ L
I I T ' I - T r : - L rl —-k~—' I - I J ____ L
t
C ITY / TOW N
J ____ LP O STA L CODE
1 1 1 1 I. . . SV; r , A .;;;.- A :i.
__1____ 1____ !_ ___!____ I___1 L I I: I J ____LN AM E OP S IC K FUN D / M EO IC A L A ID S O C IE TY 'A N D M E M B E R S H IP N U M 8ER
i - 1 ; y ------------ ---------------------------I ' r i •'* * r .1 - i ■■ I . 1 . . ' l I____ I____ [_
Surname
^ „ PARTICULARS OF PERSON RESPONSIBLE FOR PAYMENT OF THE ACCOUNTo ( r 4 ~ , f . , - v
' ------« ............... . Christian Names
;ic .Postal Address ............. ................................ Tel. N o .- . -V.;r:... .......................................................................................................
— t —Residential Address —
I.D. No. ...................................................................
Other Particulars (eg'P.'F.'WiHiBelJ'.............................. ..................................... ............................... ....... Occupation .. .................................. .......
Name and address of employer ....
J ............... Resident Permit/Passport No............ ..................................... ............--------- • i — KMsreaR ’s iadiie
Tel. No. ........................... .................................................-Vv - V
F u ll nam e o f y o u n g e s t c h ild a t s c h o o l age ................................................ ^ . - I . . ...................................... .................................. ;• • • • .................. J
N am e o f schoo l w h ic h h e /s lie a t te n d * .................................. ......... ................................................................................................... ......... s i ' " ' ' — •-V ‘
■ A s » - .
• ~ ^ - ^^'-'PARTICULARS FOR C LA S SIFICA TIO N
N U M B E R O F P E R S O N S l^ H O O S E H O C D (B re a iftv rnn e r an tf de- ' t y T ^ pendants e x c lu d in g m in o r c h ild /e n o f. 15 y e a r» ^n d o lcfer w h o are se lf-s u p p o rtin g ) ' • \A N N U A L G R O SS IN C O M E O F F A M IL Y b y w ay o f sa lary and a llow ances, b o n u s ,c o m m is s o n ,re n t d iv id e nd s e t c . , a n d / o r n e t t in co m e b y w ay o f fa rm in g , trade , in d u s try o r any b u s in e s s . . ,
‘ C4-
M onth /W e& k ear_ri_:—r-_ , yjp.- R--------------------- -
(E x c lu d in g lncO m fT n ? ? spe 'c t o f m in o r c h ild re n o f 16 yeets and o l(de»kwho are se lf-s u p p o rtin g ),
I hereby c e r u fy . th a t . th e above m e n tio n e d p a rt ic u la /s U irn ished by me ATJBLJto the b es t a f.,m V -kno w l edge u u e and c a r r e t t . ----------------
. B re ad w inn e r
W ife .
Totaf family incom e^ ,
.........................
n^^iqj i ss i c Per day N aqnina lr ( - f - 3
b y
« - D a te ................ ......................... .............
v e i l c ^ / o j y yCash R e c e iv e c L lC ^ /O J ^ g rJ
R.R ece ip t no .Date -
M ark a p p licab le b ox w ith X P L E A S E S E E O V E R L E A F F O ffF U R T H E R A D D IT IO N A L P A R T IC U LA R S
Collection Number: AK2702 Goldstone Commission of Enquiry into PHOLA PARK Records 1992-1993 PUBLISHER: Publisher:-Historical Papers, University of the Witwatersrand Location:-Johannesburg ©2012
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