.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

u ' * ^ \ 'H , (

• P i n ( 4 y • r i

< ^ 3 ", H

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p - r :

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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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