DA Form 3647-1 "Inpatient Treatment Record Cover Sheet (For Plate Imprinting)"

What Is DA Form 3647-1?

This is a military form that was released by the U.S. Department of the Army (DA) on May 1, 1979. The form, often mistakenly referred to as the DD Form 3647-1, is a military form used by and within the U.S. Army. As of today, no separate instructions for the form are provided by the DA.

Form Details:

  • A 2-page document available for download in PDF;
  • The latest version available from the Army Publishing Directorate;
  • Editable, free, and easy to use;

Download an up-to-date fillable DA Form 3647-1 down below in PDF format or browse hundreds of other DA Forms stored in our online database.

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Download DA Form 3647-1 "Inpatient Treatment Record Cover Sheet (For Plate Imprinting)"

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INPATIENT TREATMENT RECORD COVER SHEET (For Plate Imprinting)
For use of this form, see AR 40-400; the proponent agency is the Office of The Surgeon General.
PATIENT DATA ITEMS 1 - 30 (Excluding Items 25 & 26)
LINE
LEGEND
ADMISSION REMARKS
1
REGISTER NO. - NAME - GRADE
2
SEX - AGE - RACE - RELIGION -
LENGTH OF SVC - ETS - PRE-
VIOUS ADMISSION
3
FMP - SSN - ORGANIZATION -
WARD
4
FLY STAT - RATING/DESG -
DEPT/BEN - BRANCH/CORPS -
UIC/ZIP - TYPE CASE
5
SOURCE & AUTHORITY FOR
ADMISSION - HOUR OF AD-
MISSION - CLINIC SVC
6
NAME/RELATIONSHIP OF
EMERGENCY ADDRESSEE
ADMITTING OFFICER
7
ADDRESS OF EMERGENCY
ADDRESSEE - PHONE NO. -
DATE OF THIS ADMISSION
32. UNITS OF WHOLE BLOOD/
8
NAME & LOCATION OF MEDI-
COMPONENT TRANSFUSED
25. TYPE DISPOSITION
26. DATE OF DISPOSITION
CAL TREATMENT FACILITY
DATE OF INITIAL ADMISSION
31. SELECTED ADMINISTRATIVE DATA
CHECK IF CONTINUED ON REVERSE
33. CAUSE OF INJURY
34. DIAGNOSES/OPERATIONS AND SPECIAL PROCEDURES
CHECK IF CONTINUED ON REVERSE
35. TOTAL DAYS THIS FACILITY
a. ABSENT SICK
b. OTHER
c. CONV LV/COOP
d. SUPPLEMENTAL
e. BED
f. TOTAL SICK
DAYS
DAYS
CARE DAYS
CARE DAYS
DAYS
DAYS
36. TOTAL DAYS ALL FACILITIES
a. ABSENT SICK
b. OTHER
c. CONV LV/COOP
d. SUPPLEMENTAL
e. BED
f. TOTAL SICK
DAYS
DAYS
CARE DAYS
CARE DAYS
DAYS
DAYS
SIGNATURE OF ATTENDING MEDICAL OFFICER
SIGNATURE OF PAD OR MEDICAL RECORDS OFFICER
EDITION OF 1 AUG 1976 IS OBSOLETE.
DA FORM 3647-1, 1 MAY 1979
APD LC v1.01ES
INPATIENT TREATMENT RECORD COVER SHEET (For Plate Imprinting)
For use of this form, see AR 40-400; the proponent agency is the Office of The Surgeon General.
PATIENT DATA ITEMS 1 - 30 (Excluding Items 25 & 26)
LINE
LEGEND
ADMISSION REMARKS
1
REGISTER NO. - NAME - GRADE
2
SEX - AGE - RACE - RELIGION -
LENGTH OF SVC - ETS - PRE-
VIOUS ADMISSION
3
FMP - SSN - ORGANIZATION -
WARD
4
FLY STAT - RATING/DESG -
DEPT/BEN - BRANCH/CORPS -
UIC/ZIP - TYPE CASE
5
SOURCE & AUTHORITY FOR
ADMISSION - HOUR OF AD-
MISSION - CLINIC SVC
6
NAME/RELATIONSHIP OF
EMERGENCY ADDRESSEE
ADMITTING OFFICER
7
ADDRESS OF EMERGENCY
ADDRESSEE - PHONE NO. -
DATE OF THIS ADMISSION
32. UNITS OF WHOLE BLOOD/
8
NAME & LOCATION OF MEDI-
COMPONENT TRANSFUSED
25. TYPE DISPOSITION
26. DATE OF DISPOSITION
CAL TREATMENT FACILITY
DATE OF INITIAL ADMISSION
31. SELECTED ADMINISTRATIVE DATA
CHECK IF CONTINUED ON REVERSE
33. CAUSE OF INJURY
34. DIAGNOSES/OPERATIONS AND SPECIAL PROCEDURES
CHECK IF CONTINUED ON REVERSE
35. TOTAL DAYS THIS FACILITY
a. ABSENT SICK
b. OTHER
c. CONV LV/COOP
d. SUPPLEMENTAL
e. BED
f. TOTAL SICK
DAYS
DAYS
CARE DAYS
CARE DAYS
DAYS
DAYS
36. TOTAL DAYS ALL FACILITIES
a. ABSENT SICK
b. OTHER
c. CONV LV/COOP
d. SUPPLEMENTAL
e. BED
f. TOTAL SICK
DAYS
DAYS
CARE DAYS
CARE DAYS
DAYS
DAYS
SIGNATURE OF ATTENDING MEDICAL OFFICER
SIGNATURE OF PAD OR MEDICAL RECORDS OFFICER
EDITION OF 1 AUG 1976 IS OBSOLETE.
DA FORM 3647-1, 1 MAY 1979
APD LC v1.01ES
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