A. Patient’s Profile Name: Patient X Age: 13 y/o Weight: Religion: Roman Catholic Mother: Address: Tanay Rizal B. Chief Chief Compla Complaint int:: UTI Date of Admission: 1 st Admission Hospital Number: C. Histor History y of Presen Presentt Illne Illness ss D. Past Past Ill Illne ness ss E. Activi Activitie ties s of Dail Daily y Livin Living g F. Revie Review w of of Sys Sysyt ytem em