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HOSPITAAL HOSPITAL...
Afdeling Ward.... .
.0 TPH3
( j Pasikni • Patient .- * r.~~GeslagSex Y v
FOud.Age.
Pasientno. Patient’s "No. Indeling
Classification
f t J M S'— "T ADDRESSOGRAPH
/ ^ ? W 3 ^ 4 - .
M l
Geneesheer • Doctor
Q
OPNEMING • ADMISSION
Opgeneem deur DatumAdmitted by .............................................. ............................................... Date ••••
Voorlopige diagnose Provisional diagnosis.
TydTime.
Handtekening van geneesheer (indien beskikbaar) Doctor’s signature (if available)...............................
ONTSLAG • DISCHARGE
^ 0Datum van ontslag Date of discharge
Finale diagnose Final diagnosis
Handtekening van geneesheer Doctor’s signature
Ek, die ondergetekende, verlaat dieI, the undersigned, leave the
-hospitaal op my eie verantwoordelikheid Hospital on my own responsibility and
ien strydig met die advies van die behandelende geneesheer.'
' against the advice of the attending doctor. • i
Getuies 1..........Witnesses
2 .
Handtekening van pasiSnt Signature of patient...........
DatumDate............................... I.
i-.'iafeiaisfcA
..■1
Timew ' TrB’
IK.,-^ .^ -u itd ie v-C-; ^ "/•'^Ek, die ondergetekende, neem die pasient
’ I tha i mHprsinncvi takfi thfi natient.......
'the attending doctor.
Getuies ■Witnesses ' 1. ..........
‘ 2. iU sZ L
DatumDate..:.
•:v v ,a ;
.... 7~V*.
ir-.ooaia^f;
■ r rs>>r*niw 3 [•
*" if -f 1..,»h’C
^ - V- .Mj-is&iZ jTydTime
t HoedanigheidCapacity.............................................................. ..........
Vir besonderhede van behandeling gebruik vorm T.P.H. 3 (a) ....For particulars of treatment use from T.P.H. 3 (a) _ ............
A O it.v*. vr,'1 - X ; . ■ ■--------- .--------y
\ d ‘ W i i r . u i ■ A ~ • • € • '
G.P.-S. 042-0236
m
TPH 3 (b)
PROGRESS NOTE • VORDERINGVERSLAGHOSPITAL WARD / DATE ADMITTED
...........HOSPITAAL SAAL DATUMTOEGELAAT...^Z....^.X..Z.?^....
PATIENT • PASIENT
d o
PATIENT’S No. • PASIENT No. AGE • OUDERDOM
DateDatum Progress notes • Vorderingverslae
Investigations & results Ondersoeke & uitlsae
SP % jk k 7.5
f .
O T
‘ Tv%
q l x S - * ■v—o'-
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i . j 3 —-—JPlease turn over • Blaal asseblief om
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l^ A G a n g a z h eB (Natal)
J
PH 201 g 311826PROVINSIALE DIENSTE PROVINCIAL SER V IC ES
TRANSVAALHospitaal Praktyk Nr. S 7 ^ f
..............................Hospital Practice ........ .....Hospitalverskuldig vir behandeling opft O & < /' Q V for treatment received on . 1 / . 19..../ '
Mediesefonds Nr............................ Medical Aid No. ........................
DiagnoseDiagnoses
Indeling Pt. Class
.............................................. hosp. NoJaam van Pasient -lame of Patient ... Tipe diens <ind of Service :..
G.P.-S. 042-0202
KLINIESE VERPLEEGDOKUMENT
rVORDERINGSVERSLAG
Toelalingsdala (vollooi slegs mel toelating)
Temperatuur: P o lsT^P Asemhaling:
Velkleur: ~Bloeddruk:
Urienloets: - Allergiee:
Massa: Lengte:
No* Behoeftelys
= Oorsigbeeld1. Gebruik deurgaans 1 dieselfde behoefte name/nommers,
soos aangedui op TPH 114/5. , j2. Skrap opgeloste behoefte deur nommers hier langsaan deur
te haal. i -■ j3. Moenie deurgehaalde nommers hergebruik nie, tensy 'n
opgeloste behoefte weer aktief raak. i4. Verwys in onderstaande verslag slegs na behoefte nommer.
Datum Tyd *No.
H A tfG >U \....................................................... ............... ................................ ...»
^ p ^ ::p f c ............................................................................ 2 ...... ................................... g L q j Q J!)........................................\ kjX S $ 3 l. ............... ............................. ± ..... ................................... ................................ ............................
................0...............................................................................
Progressiewe notas met betrekking tot behoeftes/tussentydse inskrywings
C ^J
Handtekening en rang
< 2 ^ -2
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IIS! " ■ W ifc p ? '. r - s t m z r.-.u•»} > .
Pasi^nl: V \ < L u p L r Q9- No: \ V q A Saal: \ q Df-:03
HANDTEKENINGSIGNATURE
BESKRYWINGDESCRIPTION
DATUMDATE
HANDTEKENINGSIGNATURE
BESKRYWINGDESCRIPTION
DATUMDATE
1 * - •*vObservasie/Verpleegsorgkaart
lObservation/^lursing Care Chart
NAAM / NAME : T-P«Jk l14/f *
REG. N o .: /S 7 ^ ^
SAAL / WARD : ^
[vERPLEEGSORG / NURSING CARE : ________ ______________ ____________________________
■<*%V'gS
k o n t r o le k a a r t CONTROL CHART
N A A M /N A M E
.SAAL/W ARD
OPNAM EDAG/DAY OF ADMISSION OPERASIEDAG'DAY OF OPERATION DOKTER/DOCTOR
SitH«d*g/Day of illnest
DATUM/DATE
TYD/TIME
TEMPERATUURTEMPERATURE
INSTIUKSlEimnucTiON
POLS/PULSE
a s e m h a l in gRESPIRATION
b l o e d d r u k BLOOD PRESSURE
IN STtU K S ltIMSTlUCTlOH
STOEL& AN S/STO O LS
k l e u r / c o l o u r
r e u k / o d o h r
a p s a k s e l s / s e d im e n i
a l b u m ie n / a l b u m in
BLOED/BLOODG LU KO SE/G LU C O SE
KETONE/KETONESMASSA I MASS
Handtakaning
J
- 2 -
DATE • \DATUM
DETAILS OF., PRESCRIPTION ’’ ....... " ,V.OORSKR1F BESONDERHEDE................
/ .. . ... - -
QTY.HOEV.
PHARMACISTAPTEKER
t o '■ J? o r e q u i v a l e n t
1 4... v .j.— - ^ " o f ekwivalent. 4-— .
■ f i) C ° 'C r fe ^ 7 " or equivalent
\ /K ? i £ > ° f ekwivalent
\•Y
^ ...... - or equivalent... TT--.. ~ n ^ o f ekwivalent ,
.........V \
---- - -• - - • - • or equivalent
■ -----T« i• • y ........ ...... o f ekwivalent
__ .._, .............. or equivalentr
1
- • •s’ .......... ..... ........ ..... - • • o f ekwivalent1
• •v ............ .......... -.... ' ' or. equivalent\ .... - . •
............ ................. ....... o f ekwivalent
....... ......... or equivalent
. \ ..'... .............. ......- - .....- ..... ' " ' of,ekwivalent ; •
........ ...... ....................... . " or equivalent
• --- - of ekwivalent ; 1 :
--- ............. «-<•—•'................ ...... or equivalent** *■— - -T -n-
i' v*T'* ': - J'* • .* ‘V.
.........— • — -----------— •....... ....- - - o f ekwivalent\ -
I ,f.:i
- --- ------- --- --- ........... - • - or equivalent , i * *11
-- ------- — ...........— •----; ..... ...... o f .ekwivalent’. > ' . *• : Sf4s»
■ .!
.. ... .......................... ' "..... • or equivalent* -.-' '“‘•r 4.- ’i
.. > t i i • ,-i. hiriZCXVii.hTW. o f ekwivalent. ----- _‘ • -
, . - « . • • * A * " » * « * * * * *.:*-**• *• : '.......... . ‘ •••''* .. or equivalent
o f ekwivalentf. x-i f-i «' > * • • t\. ' .- .I ,
;rgyj, . or. equivalent. i;.— -* r- J»-w»
or equivalent
J v, v r v
CL-
TP H 152M
G.P.-S. 042-0186
^ ■ it c ^ lL \ k i v y & w - h - ^ ^ sW D . A F D (£2me • Naam Number • N t / im a r ^ ) Age • OiKTf.t
' ® I 75~) I
Classification* Indeling.uHospital • HospitaalMonth • Maand
0 7 ? / r tJ / r /£ X T '* ?
Sign. Sit Handt. ■>;
•Tima t, : Tyd .•
Date..Dag
S ig n .'/ ij Handt. si!Sign.
Handt.Oty.
Hoev.Sign.
Handt.Qty.
Hoev.Time
3ADMISSION FORM T.P.H. 1
Hospital
SURNAME —
CHRISTIAN NAMES RESIDENTIAL AOORESS— UNE-1
'■ -2
-3
■ 1 \/2 - x-. ■ / y I « '"»■I ' «•• i * -I__- i — r • l ■ . >- »* - f ---- 1----- 1----- 1-----
CLASSIFICATION
BECLASSIFICATION
D ata o f 8 ir th
M a lden N a m e ..........
N am e and A ddress o f E m p lo y e r
O c c u p a tio n /R a n k
N am e o f n e x t o f K
R es iden tia l Address
I‘ 'R a c e W
I - - 1 -
kJ
1 -7—L
i r_
M arTta l state
. . C h u rc h . . . . . . . V . . . . . .~ •") A A ^
C ongrega tion
W
J ____LO A T I OF ^ C L A S S IF IC A T IO N
J ____ LAge in Years!
I• I . . .M in is te r
...in i .......- .........r ^ r
H usband G uard ian
Nam e o f fa m ily <d o c to r .............................................. ...................................................R e fe rred to h o s p ita l b y / f ro m
^ D A T E ✓ 7 / /» /T IM E In ju ry on
d u ty *s ^ ^ R o a d
a cc id e n t*
A C C ID E N TIn case o f a cc iden t o r I r ^ u ry , s ta te
Reg. n u m b e r o f veh ic le used to tra n s p o r t p a tie n t to h osp ita l
Place
R E A S O N F O R A D M IS S IO N I " " □ In ju r y u A tte m p te d Su ic ide u A ssa u lt P o ison ing u O the r
Reason |____I
S O U R C E O F A D M IS S IO N # B ooked Case
E x O u t-P a tie n ts : O w n H osp ita l J
D e p a rtm e n t A d m it te d to : M edica l [ |
U n b o o k e d Case
O th e r H osp ita l
S
P riva te /M e d ica l A id D o c to r □
E x C a sa u lty : O w n H osp ita l I 4 \
Transfe rred □
O ther H o sp ita l □
u rgery J & . G ynaecq logy and O b s te tr ic s ! 1
N am e and A ddress o f F rie nd
T e le p h o n e n o . :
RTICJtlLARS OF PERSON RESPONSIBLE FOR PAYM EN TJ3F TJ
“ I....—4 . , , *
Surname ........ ^sSrrrfT................. ............. .— < ------- ----------------------. ^ __ _ ______________■ L - ' i'n-T*?’! -• , j >.V| Tel. No.Postal Address.
Residential Address-1 n Nn .... / ^ ' S ' ■ ' Resident Permit/Passport No. :.................. :.................. .....................—I a .............................. .........T ____ / J r - __________________________:______ -■______ _- _JMaWtd f t S te s yOther Particulars (eg P.F.'Number) ............................ ....................................................................... Occupation ..........................
Name and address of emplo ye r.................................................. . / . . ■ £ > ........ .• - —- ' ' ‘ - - . ....... .......... .Tel. No.
__,-v&ssg&*ww-•••F u ll nam e o f youhgast'ch iT d at s c h o o le g o ......... — ...................... , '*■ ** '.................. **" r * * V ’J * " * * ' * ' — \ ............. ' :
N am e o f schoo l w h ic h he/she a tte n d s .................. .• • a . . • • • • • • • • • ......................... .................................................y * - '9 • • • * u * * ••••* •*•• • • • • • • • • - i -• -?
s e lf-s u p p o rtin g ) ’ . . ’ ’ ”A N N U A L G ROSS IN C O M E OF F A M I L Y b y w a y o f sa la ry and a llow ances, b o n u s ,c o m m is jo n , . ; B r e a d w in n e r re n t d iv id e nd s , e tc ., a n d /o r n e t t Incom e by w ay o f fa rm in g , tra d e , in d u s try o r any b u s in e s s .^ ^ - .L *
: j ■■ ' ——------—. ' '■ . 'Vu : 0 - — —Wife —_o.(E x c lu d in g 'tn c o m e 'fn 're s p e c t O f ’ ^ ~ - / -*i • • * w ; 1 --------------;---------------m in o r c h ild re n o f 16 years and o ld e r w h o are ^e lf-s iy 5 p o rtin g ),.. ,r -•* ^ *• r^ -C . . T o ta l fa r i^y > inco m e 1ta l fa m i ly in c om e { — 7 v j£ jg £ & £ r j ik c * -~>
I hereby c e r t i fy th a t Xhe.abOygdTOgPt'O^^d'par by me are to " ih e best o f m v k n o w le d g e i{y j_ q n i
~ z : fu rn is h e d^Signature:
ie n t. y ^ e ' ^ U titia ls and S u m ........... * .......................................................................................................• 7 ^ * - ‘
f t * . . ........... ................................ ........... . . . . . . I . R e la tio n s h ip to p a t ie n t ............... ; ........ .............. / . r r . . .V .V .. . - .V - ------- --Cashn .. ./ ........aFO R O F F IC E U S E :
C la ss ifica tio n and T a ri
M a rk a pp licab le b o x w ith X
D a te . . . . . ’. ^ i . v . . . .
P LE 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
If a person REFUSES to furnish the particulars required for classification of the patient but elects to pay a cash d,ep°? ‘t; 'to provfde for accommodation and treatment covering a period of five days, calculated at the Wghest appl.cable tariff (tariff category P6 or PD for white and non-white persons respectively), the patient may be admitted as a PRIVATE P A l i t m . _ _
V - ' "V . ' ' Date
i i • i ~ ----- - ........
V \ - -* ' -
1 request, notwithstanding the fac t that I may be entitled to have the patient/myself classified as a HOSI- ------------------------------------- ■■ declare that 1 shall be able to pay the resulting hospital account in tun ana ipatient/myself classified as a PRIVATE PATIENT and 1 also undertake to settle such account.
“____ to'defray the cost o f the"S in c e I have no/inadequate'poveW or medical expences I hereby make a cash deposit o f R _ ------expected st^y and treatment for a period of not more than five days and I take cognisance thereot that in the event of an overpayment,, the differen^e-wHUje refun<ed to me In due c o u r s e . " ; ‘ 0 ; ! V ~ ,("D aletg ilKhot appiifcat>le).\ - ' . \ ^ ^ ___ _
---------- r - t "gijnoH _______________________ _ Deposit made R------------ 1- Receipt No. Date
's.
Special Remarks.
: , ‘.3 irv .
Date- ADMITT1NG OFFICER.
T------------------------ ~ Permission'isTie/eby granted Tor'the disclosure of the nature of my illness*/the patient’s illness fo r B c c o u h n n g ^ u r p o s e s . '- r - C ^ ^ V ^ V ^ ^ ' i»0 JAUV.V.A
— _ ________________ :_________:---------------------------- ; yrtr. n >*inubni .sb a ir^ s lro ie t l o y « w V- arnoxu7 i s c i c ' i • * . - > - * -----*•Witness— ----------------:--------------- -- ----------<1> ----------------------------------------------® S igned^— — --------------------- --
f •;----------- ---- ----- r--------— — ■ ~y ~ ; T ' - srtf'/rofcto bac .-laJV. S' »o rc ith r iry iy n
• Relationship to p a t ie n ts — ----------------; - V — ....... . . » *-■ »• v ■ »« • — :— 1------- —
, V~7y j
q 7 o n )I
A
P A T IE N T NO.
A D M IS S IO N F O R M T .P .H . 1
H QF A 0^ I S3 ION
SURNAME L -
CHFUSTIAN NAMES RESIDENTIAL . ADORESS— UNE-1
T IM E OF AO MISSION
CLASSIFICATION
RECLASSIFICATION
O A T i OF W EC LA S S IF 1C A T IO N
M a rita l sta teD ate o f B irth
M in is te rC ong rega tionC h u rc hda ld e n N am e
N am e end A ddress o f E m p lo y e r
T e lep h o ne N o.(W ork)Te lep h d na -'N o . (H om e )O c c u p a tio n /R a n k . . .
Nam e o f n e x t o f K in
R es iden tia l A dd ress .
Guard ian
,T ile p b o n e No.
R e fe rre d to h o s p ita l b y / f r o mNam e o f fa m ily d o c to r
PlaceA C C ID E N T D A T E ^ T IM E
Bag. n u m b e r o f veh ic le u red to t r a /s p o r t p a t ie n t to h o s p ita l
- R o a dicc id e n t
A t t e m p t e dS u ic id e
A ssa u ltIn ju ry ReasonR E A S O N FO R A D M IS S IO N Illness
U n b o o k e d Case T ra n s f e rre dP riv a te /M e d ic a l A id D o c to rS O U R C E O F A D M IS S IO N * B o o k e d Case |------1
E x O u t-P a tie n ts : O w n H o sp ita l .J~ D e p a rtm e n t A d m it te d t o : M ed ica l |
O th e r H o sp ita l E x C a s a u lty : O w n H o sp ita l
S u rge ry G y n a e c o lo g y and O b s te tr ics
N am e and A ddress o f F rie n d
T e le p h o n e no.
AUTHORITY / INSTITUTION POSSIBLY RESPONSIBLE FOR HOSPITAL CHARGESINITIALS
SURNAM E / INSTITUTfQI
NAME 0 / S T R E E V 7 -0 . BOX AN D NUMBER
CITY / TOWNSUBURB
NAM E OF Sl(7K FUND / MEDICAL AID SOCIETY AND MEM BERSHIP NUMBERPOSTAL CODE
PARTICULARS OF PERSON RESPONSIBLE FOR PAYM EN T OF.TI
..... .......... . . . . . . . . I . . : . ' . . . Q w s t i a n j ja m e sSurname . . . . . . ........ . . . . . . p .
Postal Address .....
Residential Address ................ .......
i.d . no . .....
Other Particulars [eg P.F. Number)
Name and address'of employer
Resident Permit/Passport No'. „:...
: . 7 : . . ^ . . . . . _ . . . : . . . Occupation
F u ll nam e o f y o un g e s t c h ild a t schoo l age• • £ -.;•«■" j/ J . * _ ' - . ; ’ ■ 1 ,*’ • i ;/ * . yjN am e o f schoo f w h ic h he /she a tte n d *
B r e a d w in n e r
^ h e r e b y ^ c e r t iV y t h a t t t i e a b o v e m c n t io n e d ‘ b y m e a re t o t h e b e s t o f m y 'k n o w le d g e t r u e a n a .c
' I f n o t p a t ie n t, s ia ^e i In it ia ls and S u r n a m e ^ - r r ^ . . . . . . ; . ^ ^ - - - * * * - * * - - * * * . * -R e la t i o n s h ip t o p a t ie n t
R e c e ip t no** D a te .D ate
P L E X S E -^E E 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
. ‘ ."•J -V J ' J - i
PROVINSIALE D IEN STE ? H 9 7 6 0 CIAL S ER V IC ES
TRANSVAALHospitaal Praktyk Nr.Ho^nital Practice No.......
- j r f “ S ’ * ' ^
^mmkm■
5 * ^ k £o £
5 5*3 s s nr-r- jrr-vA- ••
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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