© 2020 usarmydatadepot
Medical - Dossier Bank Forms

  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 est indiqué sur le facicule, ainsi que la date d'édition ou de révision.

 

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

 

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

Le document qui a été remplacé par cette nouvelle édition est indiqué à la référence.

 

 

 

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 ont été 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