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3~ <br />ORANGE COUNTY,jAIL Namc: <br />SICK CALL REQUEST DOII: <br />SS#: <br />CC: = <br />Date: Timc: am/pen <br />DfCrccr Namc _ <br />Medical OfCsite Notified: yes _ no ~ Date/Timc NutiGcd <br />Inmate Transported to Hospital: yes _ no __ <br />Subjective: <br />Objective: T- P-iR- <br />B/P- Wt- Allergies <br />AsscssrricnC t. S. <br />1. __ ~• <br />3, 7. <br />4. R, <br />Plan: 1. <br />2. <br />3. <br />4. <br />5. <br />~mcdication ordered <br />-RTC Cor F/U <br />-RTC prn <br />-sent to ER <br />~scnt Cor Xray <br />-return to jail area <br />-jail medical supcrvisipn recommended <br />_rcfcr (o dental <br />_rcfcr to psych <br />-outside referral: <br />where: <br />...........__._. <br />ATTACHMENT #1 <br />Provider 5i~nature: Date Timc am/nm <br />