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

DA Form 3647-1 - also known as the "Inpatient Treatment Record Cover Sheet (for Plate Imprinting)" - is a United States Military form issued by the Department of the Army.

The form - often mistakenly referred to as the DD form 3647-1 - was last revised on May 1, 1979. Download an up-to-date fillable PDF version of the DA 3647-1 down below or look it up on the Army Publishing Directorate website.

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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EDITION OF 1 AUG 1976 IS OBSOLETE.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

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

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