ANNEX A

PHILIPPINE HEALTH AGENDA (PHA)

_____________________________________________________
(Name of PCB Provider)
INDIVIDUAL HEALTH PROFILE & ASSESSMENT FORM

Print legibly. Mark appropriate boxes c with " " PCB PIN:
DOH Facility code: Date

Picture
(Prefix) (Last Name) (First Name)
(Last Name) (First Name)

Father's Name

(Last Name) (First Name)

Mother's Name

Blood type (if known) PWD (Y/N?) if Yes, Pls. specify

Note: If this is a follow-up consult or 2nd visit, please indicate if there are any changes in the Basic Demographic Data. Updating of th
Assessment Form must be done annually. Indicate the date when the new data has been entered. Please use additional page when ne
Address:

0 28 days 29 days11 mos 1 - 4 years 5- 9 years 10 -14 years 15 - 19 years

Age: if Pregnant if Pregnant
check age bracket &
specify age

(for 15-49 y.o. only)

WRA (women of reproductive age) NPNP(non pregnant non post-partum) Pregnant Post-partu
Male
Birthdate:
(mm/dd/yyyy)
/ / Sex:
Female
Religion:

Civil Status: Single Married Cohabitation Annulled Widowed

Pantawid Pamilya member? Y/N Household Number
PHIC Membership: Type of Membership
Member Sponsored Program Individually Paying Program (IPP)
Dependent of: NHTS LGU Organized Group

_____________________________________ NGA Private OFW

(pls. specify name) Senior Citizen
Occupation:
Highest Completed Educational Attainment:
College degree,post graduate High School Elementary Vocationa
Personal/Social History:
Smoking: Current Smoker Quitter Passive Smoker Never Smoked
Alcohol: 5 or more drinks in one occasion/month Never Consumed
Illicit drugs: Yes No If Yes, Specify:
Access to Safe Water: Yes No Access to Sanitary Toilet: Yes, encircle if OWNED or SHARED

Source of drinking water; pls. specify:

Vital Signs:
BP Height (cm)
HR Weight (kg)
RR Waist circumference (cm)
TEMP. BMI: Weight(kg)height(cm) height(cm) x 10,000
Immunizations:

For young women HPV 1 2 MMR 1 2 Flu vaccine TT/Td:

For elderly and immunocompromised: Pneumococcal vaccine 1 2

Others specify

***Assess for the general danger / warning signs: Remarks / Action Take

Chest Pain

Severe Headache

Difficulty of Breathing

Loss of Consciousness

Slurred Speech

Facial Asymmetry

Weakness/Numbness on arm/leg on one side of the body

Past Medical History:
Medications Taken Tuberculosis Diabetes
Allergy, If Yes Pls. Specify _________________________ Epilepsy/Seizure Disorder Hepatitis
Stroke Hypertension Kidney Di
Asthma Thyroid Disease Others:

Heart Attack Cancer

Past Surgical History

Family History
Allergy, If Yes Pls. Specify Tuberculosis Cancer
Epilepsy/Seizure Disorder Diabetes
Stroke Hypertension Hepatitis
Asthma Thyroid Disease Kidney Di
Heart Attack Others:
Menstrual History:
Menarche: Onset of sexual intercourse:
Last Menstrual Period: Interval/Cycle:
Period Duration: Age of Menopause:
No. of pads/day during menstruation:
Pregnancy History:
Gravidity (No. of pregnancy): Parity (No. of delivery): Type of Delivery:
Number of Full Term: Number of Premature: Number of Abortions:
Number of Living Children: Pregnancy-Induced Hypertension (Pre-Eclampsia):

Yes If Yes, Pls. Specify:

Current User? If NO, check any of the ff. Using traditional method wants to space wants to
No

(Exclusively for Physician only) Pertinent Physical Examination Findings:

GENERAL Disoriented: Time Space

Pallor (+) Surgical Scar Rashes
Skin
Bruises / Lesions Poor Skin Turgor
Ear pain/ Discharge Visual Disturbance Enlarged Thyroid
HEENT
Pale/ Yellowish Tonsilopharyngeal Conge
Conjunctiva Palpable Mass Bloody Nasal Discharge Exudates
ORAL CAVITY Mouth ulcers/ Lesions Dental Carries
HEART Abnormal Heart Rate Abnormal Heart Rhythm
CHEST & LUNGS Wheezing Crackles/ Rales Nipple Retraction Nipple Dischar
ABDOMEN Palpable Mass Tenderness
Edema Varicosities
EXTREMITIES
Gross Deformity Full and Equa

Other Significant
Findings:

For 40 years old and above, perform the following: Findings

Male: Digital Rectal Exam
Female: Pap smear / VIA
For pregnant and post-partum women, follow the existing pre-natal/post-partum check-up protocol.
Diagnosis (Pls. Write Legibly):

Management/Actions Taken:

Examined by:
_

(Middle Name) (Extension)

(Middle Name) (Extension)

(Middle Name) (Extension)

dating of this Individual Health Profile &

ge when necessary.

Zipcode
9 years 20 59 years 60 years and above
regnant

Post-partum MARPs (e.g. LGBT,sex worker)

Ethnic
Group:

owed Separated

Employed Lifetime
Government
Private

Vocational No Schooling

ked
sumed

D or SHARED toilet No
 TT/Td: 1 2 3 4 5

Flu vaccine

Action Taken
Diabetes Mellitus
Hepatitis B
Kidney Disease
Others:

Cancer
Diabetes Mellitus
Hepatitis B
Kidney Disease
Others:

ourse:

wants to limit Others, pls specify:

Person
Jaundice

d Lymphadenopathy
geal Congestion / Mouth ulcers / Lesions
dates
Gum Bleeding
Murmurs
le Discharges Palpable Mass
nderness
icosities
l and Equal Pulses

gs