PHA Individual Health Profile & Assessment Form as of Oct.09, 2017

ANNEX A P0I;IPPINE 0EA;10 A
INDI9ID=A; 0EA;10 0EA;10 P3FI;E > AEMEN1 F3M

PCB PIN: Date

Print legibly. legibly. Mark appropriate boxes c with " ü "

Picture (Prefx)

(Last Name)

(First Name)

(Last Name)

(First Name)

(Last Name)

(First Name)

Father's Name

Mother's Name P8D (./N-! if Yes, Pls. specify

Blood type (if knon!

Note: If this is a follo follow-up w-up consult consult or 2nd visit, visit, please please indicate indicate if there there are any any changes changes in the the Basic Basic emographi emographicc ata. ata. !pda" &ssessment 'orm must be done annually . Indicate the date when the new data has een entered. Please use addi"onal page

Address: A6e:

0 – 28 days

29 days–11 mos

1 - 4 years

5- 9 years

10 -14 years

15 - 19 ye

i Pregat

i Preg

chec age racet % specify age

(for "#$%& yo only!

8A (,ome o re!roduc.e age) Birthdate:

"

(mm"dd"yyyy)

Ci*il tat+s:

NPNP(o NPNP(o !regat o !ost-!artum)

"

%i %ig$e

#arried

#a$e Fema$e

&o'aitao

Pantaid Pamilya mem,er- ./N

0o+sehold N+m,er

P0IC Mem,ership:

1ype of Mem,ership

e):

Pr Pregat

Pos

eli6ion:

*u$$ed

+ido,

#emer

%!osored %!osored Progra Program m

di.idua$$y di.idua$$y Payig Payig Program Program (PP) (PP)

/e!edet o

N3%

L

6rgai7ed rou!

Pri.ate

6F+

N N*

222222222222222222222 22222222222222222222222222222222 2222222222222222 22222 (pls. specify name)

%eior &i7e

344+pa5on: 0i6hest Completed Ed+4a5onal A7ainment: &o$$ege degree!ost graduate

ig' %c'oo$

$emetary

:o

Personal/o4ial 0istory:

%mo;ig

&urret %mo;er

*$co'o$

5 or more dri;s i oe occasio"mot'

$$icit drugs

>es

A44ess to afe 8ater:

No >es

Passi.e %mo;er

Ne.er %mo;e Ne.er &osu

 >es %!eciy No

A44ess to anitary 1oilet:

>es encircle if OWNED or

o+r4e of drinkin6 ater? ater? pls spe4ify: 9ital i6ns: BP

0ei6ht (4m!

0

8ei6ht (k6!



8aist 4ir4+mferen4e (4m!

1EMP

BMI: +eig't(;g)?'eig't(cm)? 'eig't(cm) x 10000

Imm+ni@a5ons: For yo+n6 omen

0P9

1

2

MM

For elderly and imm+no4ompromised:

1

2

Fl+ *a44ine

Pne+mo4o44al *a44ine 1

2

3thers spe4ify Assess for t!e "eneral dan"er # $arnin" si"ns% C!est Pain Severe Heada'!e Di*'ulty of Breat!in" +oss of Cons'iousness Slurred S,ee'! -a'ial Asymmetry Wea&ness#Numbness on arm#le" on one side of t!e body

Remar&s # A'

Past Medi4al 0istory:

#edicaos 3a;e

3uercu$osis

/ia

!i$e!sy"%ei7ure /isorder

e!

%tro;e

y!ertesio

Aid

*st'ma

3'yroid /isease

eart *=ac;

&acer

*$$ergy  >es P$sB %!eciy

EEEEEEEEEEEEEEEEEEEEEEEEE

6t'e

Past +r6i4al 0istory

Family 0istory

*$$ergy  >es P$sB %!eciy

%tro;e *st'ma

3uercu$osis

&a

!i$e!sy"%ei7ure /isorder

/ia

y!ertesio 3'yroid /isease

e! Aid 6t'

eart *=ac; Menstr+al 0istory:

#earc'e

6set o sexua$ itercour

Last #estrua$ Period

ter.a$"&yc$e

Period /urao

*ge o #eo!ause

NoB o !ads"day durig mestruao

Pre6nan4y 0istory:
Parity (No of deli*ery!:

3y!e o /e$i.ery

N+m,er of F+ll 1erm:

N+m,er of Premat+re:

Numer o *oros

N+m,er of ;i*in6 Children:

Pre6nan4y$Ind+4ed 0ypertension (Pre$E4lampsia!: >es

C+rrent =serNo

 >es P$sB %!eciy sig tradioa$ met'od

 N6 c'ec; ay o t'e B

,ats to s!ace

,

(E.'lusively for P!ysi'ian only ! Per5nent Physi4al E)amina5on Findin6s:
/isorieted Pa$$or

3ime

%!ace

(G) %urgica$ %car

Cas'es

kin

@ruises " Lesios

Poor %;i 3urgor

ar !ai" /isc'arge 0EEN1

Pa$e" >e$$o,is' &oHuc.a

:isua$ /isturace Pa$!a$e #ass

$arged 3'yroid

@$oody Nasa$ /isc'arge

3osi$o!'arygea xudat

3A; CA9I1.

#out' u$cers" Lesios

/eta$ &arries

0EA1

*orma$ eart Cate

*orma$ eart C'yt'm

+'ee7ig

Ni!!$e Cetraco

C0E1 > ;=N< ABD3MEN

&rac;$es" Ca$es

Ni!!$e

Pa$!a$e #ass

3ede

dema

:arico

ross /eormity

Fu$$ a

EX1EMI1IE

3ther i6ni4ant Findin6s:

For % years old and a,o*e perform the folloin6:

Findin6s

#a$e Di6ital e4tal E)am Fema$e Pap smear / 9IA -or ,re"nant and ,ost/,artum $omen0 follo$ t!e e.isn" ,re/natal#,ost/,artum '!e'&/u, ,roto'ol1 Dia"nosis (Pls1 Write +e"ibly)%

Mana6ement/A45ons 1aken:

E)amined ,y:

(#idd$e Name)

(xtesio)

(#idd$e Name)

(xtesio)

(#idd$e Name)

(xtesio)

g of this Individual #ealth Pro$le % hen necessary.

ip4ode ars

20 – 59 years

I0 years ad ao.e

at

t-!artum

#*CPs (eBgB L@3sex ,or;er) Ethni4
d

%e!arated

m!$oyed

o.ermet

Pri.ate

caoa$

Lieme

No %c'oo$ig

ed

HARED toilet

No

11/1d:

1

2

J

Fl+ *a44ine

n a&en

4

5

etes #e$$itus as @ ey /isease rs

cer etes #e$$itus as @ ey /isease ers se

ats to $imit

6t'ers !$s s!eciy

Perso Kaudice

Lym!'adeo!at'y $ &ogeso " s

#out' u$cers " Lesios

um @$eedig

#urmurs

isc'arges

Pa$!a$e #ass

ess ies d Dua$ Pu$ses

PHA Individual Health Profile & Assessment Form as of Oct.09, 2017

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