Nigerian Paper Health Forms
The following forms are scans from actual paper forms being used at health facilities in Nigeria. We have included both individual patient forms as well as patient registers.
National Forms
- FOREWORD NHMIS POLICY DOC
- NHMIS POLICY DOC
- NHMIS INSTRUCTIONAL MANUAL
- NHMIS INSTRUCTIONAL MANUAL register
State Forms
Kano State
Hospitals Management Board
(retrieved/scanned from Minjibir General Hospital)
- Bed Head Ticket [PDF Scan]
- Free Ante-Natal Care Programme [PDF Scan]
- Haematology Request [PDF Scan]
- VCT Laboratory Result Form [PDF Scan]
- Laboratory Request & Report Form: Chemical Pathology [PDF Scan]
- Hospital Referral Form [PDF Scan]
- Request for X-Ray Examination [PDF Scan]
- Out Patient Register [PDF Scan]
- Abortion Form [PDF Scan]
- Antenatal Card [PDF Scan]
- General ANC Register [PDF Scan]
- Admission and Discharge Register [PDF Scan]
Ministry of Health – Department of Primary Health Care – Medical Field Unit
(retrieved/scanned from Minjibir General Hospital)
Kaduna State
(retrieved/scanned from Family Health Unit, SICHST)
Teaching Hospitals
Aminu Kano Teaching Hospital
AKTH is located in Kano, however AKTH DOES NOT use State forms or Reports
Forms and Cards
- Patient Confidentiality Folder [PDF Scan]
- Patient’s Personal Reference Card [PDF Scan]
- Optical Prescription Form [PDF Scan]
- T.P.R. and BP Chart [PDF Scan]
- Master Index Card [PDF Scan]
- Labour Records [PDF Scan]
- Primary Health Center Child Health Card [PDF Scan]
- Optical Workshop Card [PDF Scan]
- Special Investigation Report Mount Sheet [PDF Scan]
- Prescription Form [PDF Scan]
- X-Ray Tracer Card [PDF Scan]
- Treatment Sheet [PDF Scan]
- Out-Patient Appointment List [PDF Scan]
- Head Injury Form [PDF Scan]
- Notice For Emergency Operation [PDF Scan]
- Spasm Chart [PDF Scan]
- Operation Notes [PDF Scan]
- Operation List [PDF Scan]
- Ophthalmology Department-Optical Prescription Form [PDF Scan]
- Medical Certificate of Death [PDF Scan]
- Medical Examination Certificate [PDF Scan]
- Excuse Duty Certificate [PDF Scan]
- Certificate of Birth [PDF Scan]
- Appointment Slip [PDF Scan]
- Daily Ward Statement [PDF Scan]
- Observation Chart [PDF Scan]
- Clinical Notes [PDF Scan]
- Request for Consultation [PDF Scan]
- Diabetic Chart [PDF Scan]
- Endoscopy Report [PDF Scan]
- Lab Request Form Histopathology [PDF Scan]
- Histology/Cytology Report [PDF Scan]
- Blood Transfusion Request Form [PDF Scan]
- Admission Discharge Summary [PDF Scan]
- Continuation Sheet [PDF Scan]
- Progress Note [PDF Scan]
- Radiology Request Card [PDF Scan]
- Radiology Report Form [PDF Scan]
- Microbiology Laboratory Form [PDF Scan]
- Haematolog Laboratory Form [PDF Scan]
- Chemical Pathology Report Form [PDF Scan]
- Request Form [PDF Scan]
- Fluid Balance Chart [PDF Scan]
- Disease Index Card [PDF Scan]
- Operation Index Card [PDF Scan]
Registers/Log Books
- Accident and Emergency Register [PDF Scan]
- Maternity In-Patient Register [PDF Scan]
- Admission & Discharge Register [PDF Scan]
- Mortality Register [PDF Scan]
Collating Forms and Reports
- Daily Ward Statement [PDF Scan]
- Daily Ward Statement Cumulative [PDF Scan]
- In-Patient’s Services Monthly Statistical Report [PDF Scan]
- AKTH Statistical Summary Report [PDF Scan]
International Health Agencies Forms
Pathfinder International
Patient Registers
- CC-PPH Project [PDF Scan]
- Reproductive Health Patient Daily Register [PDF Scan]
- Client Register for Community Based Distributor [PDF Scan]
Collating and Reporting Forms
- Monthly Health Facility Activity Record [PDF Scan]
- Monthly Collating Activity Worksheet for Facilities [PDF Scan]
- Monthly Collation Sheet for TBA and CBD Activities [PDF Scan]
- Quarterly Service Delivery Reporting From [PDF Scan]
Institute of Human Virology in Nigeria
Clinical Forms [.zip]
HCT Forms [.zip]
National OVC forms [.zip]
PMTCT Summary Forms [.zip]