Facility Code

Family Serial Number DOH-00000034499

CITY HEALTH CENTER V

BLK 82, MAGSAYSAY ROAD, STA CRUZ III, CITY OF SAN JOSE DEL MONTE, BULACAN

INDIVIDUAL TREATMENT RECORD

I. PATIENT INFORMATION
Last Name Suffix
(e.g. Jr., Sr., II, III)
First Name Please write Maiden Name (for married women)

Middle Name

Sex Female Male Mother’s Name

Birth Date (mm/dd/yyyy) / /

Birthplace
Residential
Blood Type
Address
Single Widow/er

Married Separated
Civil Status
Annulled Co-Habitation Contact Number
DSWD NHTS? Yes No
Spouse’s Name Facility Household
No.

Educational No Formal Elementary 4Ps Member? Yes No

Attainment Education
Household No.
High School Vocational PhilHealth Yes No
Member?
College Post Graduate Status Type: Member Dependent

Employment Student Unknown PhilHealth No.

Status
Employed Retired FE – Private:

None/Unemployed FE – Government:
If Member, please
Father Mother indicate category IE:
Family Member
Son Daughter Others:
Others (Iba) Primary Care Yes No
BenefitMember?
(PCB)
II. PATIENT’S CONSENT
IN ENGLISH SA FILIPINO
I hereby allow the health worker of City Health 12 to perform Pinahihintulutan ko ang kawani ng City Health Center 12 upang mag sagawa ng
____________________ for me/ my child/family member. I _________________ para sa akin/anak/kamag-anak. Nauunawaan ko na ito ay
understand that this will help me in my health care needs and that makakatulong upang matugunan ang pangkalusugang pangangailangan namin, anu man
whatever the effects on me, the staffs will not be held liable. ang maging epekto nito, at wala pong pananagutan ang mga kawani o ahensya.

"No Balance Billing" was explained.

I allow the facility to encode my information in their Naipaliwanag sa amin ang "No Balance Billing".
electronic database that will enable the facility for a better
safekeeping and data retrieval for my next follow up Higit pa rito pinahihintulutan ko ang pasilidad na irecord ang akng impormasyon sa
consultation. kanilang electronic database upang mas mapabuti ang paglalakip ng aking record para sa
mga susunod kong konsultasyon.
Furthermore, I understand that there can be some financial
expenses if there is a need for referral to a higher facility that will cater
my health care needs.
Nauunawaan ko din na maaaring may gastusin kami kung sakaling kami ay kailngan
mai-sangguni sa mas malaking pasilidad upang kami ay mabigyan ng nararapat na
serbisyo pangkalusugan.

SIGNATURE OF PATIENT / DATE NAME OF CHU/RHU REPRESENTATIVE

CITY HEALTH CENTER | FORM 1

DATE & TIME OF CONSULT: NCD RISK ASSESSMENT (20 Y/O ABOVE)
Yes No Yes No
Have you had
Eats Processed food (e.g, any discomfort or
CHIEF COMPLAINT: Instant noodles, Burgers, heaviness in your
Fries, Canned Good) chest?
weekly?
Do you get the
HISTORY OF PRESENT ILLNESS: Does at least 2.5hrs of
ppain in the
moderate to intensity
center of your
physical activity? Do you
Does the pain go away chest ? stop or
slow down when
when you take a rest or
you experience
take medicine under your
chest pain while
tongue?
walking?
Does the pain
from pain across
Does the pain go away
your chest last
within minutes?
for more that an
PAST MEDICAL HISTORY: hour?
( ) Hypertension Have you had
Eats Processed food (e.g,
( ) Cerebrovascular Disease Instant noodles, Burgers, any discomfort or
Fries, Canned Good) heaviness in your
( ) Diabetes Mellitus weekly? chest?
( ) Bronchial Asthma
Have you ever had any experience of the following:
( ) Bronchial Asthma Difficulty in talking, weaknesson legs and arms in one side
of the body numbness on one side of the body?
( ) Bronchial Asthma
( ) Bronchial Asthma REMARKS:

FAMILY MEDICAL HISTORY: PHYSICAL EXAMINATION

( ) Hypertension GENERAL: ( ) conscious, ( )coherent, ( ) not in cardiorespiratory distress
( ) Cerebrovascular Disease BP: PR: RR: T: O2sat: Wt: Ht:
( ) Diabetes Mellitus HEENT: ( ) sclerae, ( ) palpebral conjunctiva, ( ) nasoaural discharge,
( ) Bronchial Asthma ( ) tonsilopharhyrngeal congestion, ( )cervical lymphadenopathy
( ) Cancer________________________ CHEST/LUNGS: ( ) chest expansion, ( ) retractions, ( ) breath sounds,
Others:______________________________ HEART: ( ) precordium , ( ) rate, ( ) rhythm, ( ) murmur

PERSONAL AND SOCIAL HISTORY: ABDOMEN: ( ) soft, nontender

( ) Smoker ________ packs per year EXTREMITIES: ( ) pulses, ( ) edema, ( ) cyanosis

( ) Alcoholic beverage drinker _____ bottles per day PELVIC EXAM:

( ) Illicit dr Illicit drug use OTHER PERTINENT PE:

Others:______________________________
MENSTRUAL HISTORY:
MENARCHE- ____ years old
IRREGULAR/REGULAR- regular / irregular ASSESSMENT/ DIAGNOSIS:
DURATION - _______days
AMOUNT - _______-pads /day
SYMPTOMS - ( ) dysmenorrhea
SEXUAL HISTORY:
Age of 1st coitus: ________ years old
No. of sexual partners: ______
( ) Family Planing _________________
( ) Dyspareunia
( ) Postcoital bleeding
OB HISTORY:
G ______ P _______ ( )

Year Sex Outcome Method Place FMC PLAN;

G1

PNCU x _______ at ______________________________

( ) Multivitamins ( ) FeSO4 ( ) Maternal Illness

REVIEW OF SYSTEMS:
General: ( ) weight loss, ( ) weight gain
HEENT: ( ) headache, ( ) blurring of vision, ( ) tinnitus
Respiratory: ( ) cough, ( ) colds, ( ) difficulty of breathing
Cardiovascular: ( ) palpitations,( ) paroxysmal Nocturnal Syspnea,
( ) orthopnea
Abdominal: ( ) abdominal pain,( ) change in bowel movement,
( ) Nausea,( ) Vomiting, ( ) Melena
Gut: ( ) Dysuria, ( ) hematuria, ( ) frequency, ( ) incontinence
Endocrinologic: ( ) polydipsia, ( )polyphagia, ( )polyuria
Hematologic: ( ) easy bruising, ( )prolonged bleeding, ( )cyanosis