MED- Bank Forms

    Dossier du G.P.O.                                                                                                                   
      

 Medical Department - Bank Forms

Photos issues de la collection Gérard Delavallée.

(Sauf mentions contraires)

Les photos sont la propriété du site. Reproduction interdite.

 

 

Cette rubrique correspond au référencement de formulaires spécifiques, qui seront utilisés par les membres du Medical Department. Ils sont référencés dans la classification "Bank Forms" au catalogue MED de 1944.

 

Ces documents seront imprimés pour le compte du Medical Department par le bureau des imprimeries du gouvernement américain (G.P.O.).

 

Le code article sera indiqué sur le facicule, ainsi que la date d'édition ou de révision.

 

Indication par des chiffres, correspondante à la matrice d'impression du Government Printing Office.

 

 

A partir de 1944, les facicules, lorsqu'ils seront revus, auront un nouveau numéro en WD AGO Form 8-""".

Le document qui sera remplacé par cette nouvelle édition, sera indiqué au code article.

 

 

 

No. Désignation
  Form 1 Report of change of status civilian employees Medical Department
  Form 2 Certificate of authority hospital unit Organized Reserves
  Form 5 Purchase description card
  Form 6 Receiving report. (MSD)
  Form 7a Item procurement card "A" (MSD)
  Form 7b Item procurement card "B" (MSD)
  Form 8a Contrat and purchase order card "A" (MSD)
  Form 8b Contrat and purchase order card "B" (MSD)
  Form 11 Stock record card (MSD)
  Form 12 Stock report card (MSD)
  Form 13 Shipping ticket (MSD)
  Form 14 Daily journal of receipts and issues (MSD)
  Form 16a Issue slip, expendable medical property
  Form 16b Issue slip, nonexpendable medical property
  Form 16c Credit slip, nonexpendable medical property
  Form 16d Credit clip, nonexpendable medical property
  Form 17 Return of medical property cover card cover
  Form 17a Return of medical property slip, original
  Form 17b Return of medical property slip, retain
  Form 17c Return of medical property cover card and back
  Form 18b Statement of expenditure of special dental materials
  Form 18b-L Statement of expenditure of special dental materials - Central Dental Laboratory
  Form 20 Caution slip (for packing cases containing medical supplies) (MSD)
  Form 21 Hospital laundry list
  Form 25 Public voucher for medical attendance
  Form 25a Public voucher for medical attendance - memorandum
  Form 27 Public voucher for hospital care and treatment
  Form 27a Public voucher for hospital care and treatment - memorandum
  Form 28 Public voucher for personal services - nursing
  Form 28a Public voucher for personal services - nursing - memorandum
  Form 39 Circular advertisement and proposal for laundry work
  Form 40 Abstract of proposals (large)
  Form 40a Abstract of proposals (small)
  Form 42 Contract for laundry work
  Form 42a Contract for laundry work appendix sheet "A"
  Form 44 Contract with a private physician for full-time service as a contract surgeon U.S. Army
  Form 44a Special contract with a private physicia for services as contract surgeon U.S. Army (limited service)
  Form 49 Statement of the Hospital Fund
  Form 49a Employee's certificate of indebtedness for hospital service
  Form 51 Report sheet for report of sick and wounded
  Form 52 Register card
  Form 52a Index of patients (card)
Form 52b Emergency Medical Tag (20 in Booklet in Duplicate)
  Form 52c Field medical card
Form 52d Field medical record jacket
  Form 52e Transfer slip
  Form 52 C-1 Clinical record, physical examination
  Form 52-9 Hospital record of death
  Form 53 Clearing station tag
  Form 54 Surgeon's request for service record
Form 55 A Clinical record, brief
  Form 55 B Clinical record, chief complaint, condition on admission, previous personal history
  Form 55 C-2 Clinical record, special examination or additional data
  Form 55 D Clinical record, initial summary, working diagnosis, contemplated laboratory tests and consultations
  Form 55 E-1 Clinical record, consultation request and report
Form 55 E-2 Clinical record, ophthalmologic examination
Form 55 E-3 Clinical record, ear, nose and throat examination
  Form 55 E-4 Clinical record, dental examination
  Form 55 E-5 Clinical record, dental report
  Form 55 E-6 Clinical report, proctoscopic examination
  Form 55 E-7 Clinical record, urologic examination
  Form 55 E-8 Clinical record, gynecologic examination
  Form 55 E-9 Clinical record, allergy examination
Form 55 F Clinical record, progress notes
  Form 55 G-1 Clinical record, treatment
  Form 55 G-2 Clinical record, diabetic report
  Form 55 H-1 Clinical record, temperature, treatment, nurse's notes
Form 55 H-2 Clinical record, temperature, graphic chart
  Form 55 I Clinical record, graphic chart
Form 55 J Clinical record, electrocardiograph report
  Form 55 K-1 Clinical record, radiologic record
  Form 55 K-2 Clinical record, radiologic report
  Form 55 K-3 Clinical record, record of roentgen therapy
  Form 55 K-4 Clinical record, record of radium therapy
  Form 55 L Clinical record, laboratory reports
  Form 55 L-1 Clinical record, blood
  Form 55 L-2 Clinical record, blood (chemistry)
  Form 55 L-3 Clinical record, serology
  Form 55 L-4 Clinical record, spinal fluid
Form 55 L-5 Clinical record, urinalysis
  Form 55 L-6 Clinical record, urinalysis (quantitative)
  Form 55 L-7 Clinical record, sputum
  Form 55 L-8 Clinical record, gastric analysis
  Form 55 L-9 Clinical record, feces
  Form 55 L-10 Clinical record, carbohydrate tolerance
  Form 55 L-11 Clinical record, renal function (conc. or dil.)
  Form 55 L-12 Clinical record, renal function (P.S.P.)
  Form 55 L-13 Clinical record, renal function (urea clearance)
  Form 55 L-14 Clinical record, basal metabolism
  Form 55 L-15 Clinical record, miscellaneous
  Form 55 M Clinical record, pathological examination of tissue
Form 55 N Clinical record, physiotherapy record
  Form 55 O-1 Clinical record, preoperative examination and anesthetic record
  Form 55 O-2 Clinical record, operation report
  Form 55 O-3 Clinical record, authorization for operation or spinal puncture
  Form 55 P Clinical record, fracture record
  Form 55 Q-1 Clinical record, prenatal record
  Form 55 Q-2 Clinical record, labor record
  Form 55 Q-3 Clinical record, neonatal record - sex
  Form 56 Malarial register
  Form 57 Report of dental services
  Form 58 Physical reconstruction register
  Form 59 Report of examination for sergeant, staff sergeant, technical sergeant and master sergeant, Medical Department
  Form 59a Report of examination for sergeant, staff sergeant, technical sergeant and master sergeant, Medical Department (TACTICAL)
  Form 59b Report of examination for sergeant, staff sergeant, technical sergeant and master sergeant, Medical Department (VETERINARY)
  Form 60 Certificate of proficiency, general enlisted men, MD field hospital or ambulance company
  Form 60a Certificate of proficiency, enlsited men Medical Department detachment
  Form 60b Certificate, enlisted speacialists' courses, Medical Department Proffesional Service Schools
  Form 60c Certificate or proficiency, Army Nurse Corps (Anesthetist)
  Form 61 Certificate of identity (in books of 100 sheets each)
  Form 62 Efficiency report, Army Nurse Corps
Form 63 Report of physical examination
  Form 64 Morning report, Army Nurse Corps
  Form 65 Dental engaement slip
  Form 66 Record of assignment and pay, Army Nurse Corps
  Form 67 Diploma, basic courses, Army Medical School
  Form 67a Diploma, basic courses, Army Dental School
  Form 67b Certificate of graduation, Medical Field Service School
  Form 67c Certificate of proficiency special subjects, Medical Field Service School
  Form 67d Diploma, basic courses, Army Veterinary School
  Form 67e Diploma, basic courses, Army Veterinary School
  Form 67f Certificate of internship in Army Hospitals
  Form 67g Certificate, advanced courses Army Medical School
  Form 67h Certificate, advanced courses, Army Dental School
  Form 67j Certificate, advanced courses, Army Veterinary School
  Form 67k Certificate, hospital training courses in anesthesia or laboratory technic for nurses
  Form 67m Certificate, hospital training courses in physiotherapy
  Form 67n Certificate, hospital traininng courses in dietetics
  Form 67p Certificate, hospital training courses in occupational therapy
  Form 68 Nurse's bedside notes
  Form 70 Chief surgeon's directory (card)
  Form 71 Surgeon's morning report of sick
  Form 71V Veterinarian's morning report of sick animals
  Form 72 Morning report of ward
  Form 72a Consolidated morning report of wards
  Form 73 Diet Card
  Form 74 Mess account
  Form 75 Patient's property card
  Form 76 Patient's property tag
  Form 77 Venereal prophylaxis slip
  Form 78 Syphilitic register
Form 78a Treatment record
  Form 79 Register of dental patients (card)
Form 81 Immunization register
  Form 85 Vital statistic chart
  Form 85a Vital statistics chart (small)
Form 86ab Statistical report, first and second sections
Form 86c Statistical report - third section (personnel and transportation)
  Form 86f Report of casualties
  Form 88 Record of physical examination
  Form 90 Efficiency and preference report of master, technical, and staff sergeants, Medical Department
  Form 94 Report of sanitary chemical analysis of water
  Form 95 Report of bacteriological examination of water
  Form 97 Record of serological reactions for syphilis
  Form 99 Gonococcis fixation card
  Form 100 Recruit depot Wassermann card
  Form 101 Veterinary health certificate
  Form 102 Veterinary report of sick and wounded animals
  Form 103a Veterinary sanitary report of animal transport
  Form 109 Record and report physical examination of animals for purchase
  Form 110 Report of veterinary meat and dairy hygiene and forage inspection
  Form 113 Trip report veterinary transport service
  Form 115 Register card for sick and wounded animals
  Form 115a Index card register of animal patients
  Form 115b Emergency veterinary tag (20 in book in duplicate)
  Form 116 Receipt for animals (50 in book in duplicate)
  Form 123 Label, penalty (for mailing dental appliances)
  Form 124 Prosthetic case record
  Form 125 Caution slip (for mailing cases containing dental appliances)
  Form 126 Report of central dental laboratories
Form 140 Report of a contact of veneral disease
  Form 200 Report of survey
  Form 322a Abstract of funds received from sales of medicines to civilians (exhibit to account current)
Form 351 Voucher for commutation of rations in hospital
  Form 352 Voucher for purchase of medicines on prescriptions
  Form 354 Voucher for examining and vaccinating recruits by civilian physicians
  Form 377 Voucher for reimbursement of medical bills
  Form 445 Requisition
Form 446 Property issue slip
Form 446a Property issue slip requisition
Form 447 Property turn-in slip
                              

 

Le tableau ci dessous correspond à des révisions des formulaires qui seront effectuées à partir de 1944.

 

No. Désignation
  Form 8-5 Hospital linen request
Form 8-23 Report sheet of sick wounded (Remplace Form 51 )
Form 8-24 Reports control (Remplace Form 52)
Form 8-26 Emergency Medical Tag (20 in Booklet in Duplicate) - (Remplace Form 52b)
  Form 8-29 Clearing station tag (Remplace Form 53)
Form 8-33 Clinical record brief (Remplace Form 55a)
  Form 8-36 Chief complaint and condition on admission
  Form 8-37 Physical examination
  Form 8-39 Initial summary, working diagnosis, contemplated laboratory tests, and consultations
Form 8-40 Consultation request and report (Remplace Form 55 E-1)
  Form 8-51 Progress notes
  Form 8-57 Temperature graphic chart
Form 8-63 Radiological report (Remplace Form 55 K-2)
  Form 8-66 Laboratory reports
  Form 8-67 Blood slip
Form 8-69 Serology slip (Remplace Form 55 L-3)
  Form 8-71 Urinalysis slip
  Form 8-73 Sputum slip
  Form 8-74 Gastric analysis
  Form 8-75 Feces slip
  Form 8-76 Carbohydrate tolerance slip
  Form 8-81 Miscellaneous slip (clinical record)
  Form 8-107 Ward morning report
  Form 8-109 Diet slip
  Form 8-111 Patient's property slip
  Form 8-112 Patient's property tag
  Form 8-114 Syphilis register
  Form 8-115 Patient's record of syphilis treatment
Form 8-116 Report of dental survey (Remplace Form 79)
Form 8-117 Immunization register (Remplace Form 81)
Form 8-122 Statistical health report (Remplace Form 86ab)
Form 8-140 Monthly sanitary report
Form 8-143 Prosthetic case record (Remplace Form 124)
  Form 8-149 Requisition for teeth and facings
  Form 8-166 Roster of seriously ill
  Form 8-167 Removal from seriously ill list
  Form 8-168 Report seriously ill
  Form 8-176 Diagnosis slip
  Form 8-178 Patient's deposit certificate
  Form 8-219 Death tag
  Form 8-225 Nursing notes and treatment record
  Form 8-231 Consultation report
     

 

 

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