Non- Communicable Diseases
INDIVIDUAL TREATMENT RECORD
Date Registered: _______________________________ Patient ID #:________________
Name: _______________________________ Birthday:_________________ Sex:_ Male _Female
Address: _______________________________ Contact #:___________________
NHTS ID #: _____________________________4P's ID #:__________________ PHIC ID #:__________________
PWD ID #: _____________________________Indigenous people Ethnic Group:________________
Non- Communicable Disease Category (Date=Date of registration of disease)
Diabetes Date___________________ Hypertension Date_______________ Asthma Date_______________
Cataract Date___________________ EOR Date_______________ COPD Date_______________
Other Eye Disease Date_______________ Alchololism Date_______________ Diabetic Retinopathy Date___________
At Risk for Suicide Date_______________ Other Medical Disorders Date_______________ Sustance Abuse Date_________
PHILPEN SCREENING DISABILITY ASSESSMENT (WHO-DAS)
Date:______________________ Date:______________________
__Current Smoker __Passive Smoker __Stopped > a year Part I: __No Difficulty __Refer
__Sopped Less than a year __Never Smoked Part II: Total Disabilty Score:_____
__Never Drinks Alcohol __Drinks Alcohol Top 1 Domain:_______________________
__Had 5 drinks or more in 1 occasion in a month Top 2 Domain:_______________________
__Dietary Risk Factors __Physical Inactivity Top 3 Domain:_______________________
Height:_______m Weight: _____kg BMI:_____
Waist circumference:__________cm
HISTORY EYE SCREENING
Lenght of Diabetes: __Floaters __Burred Vision __Fluctuating vision __Impaired Color Vision
_______mos or yrs __Dark/ empty areas of vision __Vsion loss
Lenght of hypertension: Visual Acuity Test Result: Left eye:______________ Right eye:________________
_______mos or yrs Opthalmoscopy Results:_______________________________________________
INITIAL VISIT ASSESMENT
DATE/ MONITORING CHIEF COMPLAINT / HISTORY / PHYSICAL
MANAGEMENT
PARAMETERS EXAMINATION / DIAGNOSIS
Date:______________ Complaint:____________________________
Age:_______________ History / Physical Examination:
CVD RISK:_______%
BP:______ CR:_____
RR:______ T:______
WC:______cm
Wt:______kg
BMI:______
FBS/RBS:_____mmol/L
T.Chole:______mmol/L
Urine Protein:_______
Diagnosis:
Foot Risk:________
FOLLOW-UP VISITS
DATE/ MONITORING CHIEF COMPLAINT / HISTORY / PHYSICAL
MANAGEMENT
PARAMETERS EXAMINATION / DIAGNOSIS
Date:______________ Complaint:____________________________
Age:_______________ History / Physical Examination:
CVD RISK:_______%
BP:______ CR:_____
RR:______ T:______
WC:______cm
Wt:______kg
BMI:______
FBS/RBS:_____mmol/L
T.Chole:______mmol/L
Urine Protein:_______
Diagnosis:
Foot Risk:________
Date:______________ Complaint:____________________________
Age:_______________ History / Physical Examination:
CVD RISK:_______%
BP:______ CR:_____
RR:______ T:______
WC:______cm
Wt:______kg
BMI:______
FBS/RBS:_____mmol/L
T.Chole:______mmol/L
Urine Protein:_______
Diagnosis:
Foot Risk:________
Date:______________ Complaint:____________________________
Age:_______________ History / Physical Examination:
CVD RISK:_______%
BP:______ CR:_____
RR:______ T:______
WC:______cm
Wt:______kg
BMI:______
FBS/RBS:_____mmol/L
T.Chole:______mmol/L
Urine Protein:_______
Diagnosis:
Foot Risk:________
Patient ID #:________________
Sex:_ Male _Female
PHIC ID #:__________________
Top 1 Domain:_______________________
Top 2 Domain:_______________________
Top 3 Domain:_______________________
Family #:_______________________
NHTS #:
NHTS: ___CCT ___NON-CCT
AP RECORD PHIC: ___EMPLOYED PHIC #:
Contact #: ___SELF
Date Registered to TCL: EMPLOYED
Date of birth: Age: Tribe:
LAST NAME: FIRST NAME: MIDDLE NAME:
COMPLETE ADDRESS HUSBAND/ LIVE-IN NAME BHW:
STREET PUROK BARANGAY
TETANUS TOXIOD RECEIVED OBSTETRICAL HISTORY
TT1 TT2 TT3 TT4 TT5 G P T P A L
Height: ________cm POSTPARTUM RECORD
MONTH DAY YEAR MONTH DAY YEAR
LMP Date of Delivery
MONTH DAY YEAR
EDC Place of Delivery __Gov't ___Private
Where to Deliver: Birth Attendant ___Doctor ___Nurse ___Midwife ___ Hilot
Risk Code: Type of Delivery ___Normal ___CS ___Others:__________
Seen by a Doctor __Yes __No Date:____________ 24hours to 7days PP __Yes __No Date:________
Seen by a Dentist __Yes __No Date:_____________Given Vitamin A __Yes __No Date:________
Laboratory (Date:_____________________) 4th to 6th week visit __Yes __No Date:________
Hgb:________ Blood Type:______ Urinalysis:________Birth Weight ______________gms
IRON SUPPLEMENTATION Sex of Baby ____Male ____Female
1ST TRI 2ND TRI 3RD TRI Newborn Screening __Yes __No Date:________
Hepa B Date Given:_____________
AP VISITS BCG Date Given:_____________
VITAL SIGNS ASSESSMENT Follow-
Date REMARKS up visit
BP WEIGHT AOG
1ST TRI
2ND TRI
3RD TRI
Family #:_______________________
UNDER SIX TREATMENT NHTS #:
NHTS: ___CCT ___NON-CCT
0-71 Months PHIC: ___EMPLOYED PHIC #:
___SELF
Contact #: EMPLOYED
Date Registered to TCL: Date of birth: Age: Tribe:
LAST NAME: FIRST NAME: MIDDLE NAME: Sex Birth Order
Birth Weight (kg) Birth Lenght (cm) Type of Birth
____Normal Spontaneous ____ Cesarian Section
Place of Delivery Birth Attendant Initated Breastfeeding
__Gov't ___Private __Doctor __Nurse __Midwife __ Hilot __Yes __No Date:_______
Undergone Newborn Screening Date Birth Register at LCR:
Date taken:_____________ Date Result:_______________
Mother's Name: Father's Name:
Latest Tetabus Toxiod Received/ Date Given: (Mother) Child Protected at Birth: __Yes __No
COMPLETE ADDRESS BHW:
STREET PUROK BARANGAY
IMMUNIZATION SERVICES
Date Given Follow-up
Vaccine visit
REMARKS
1 2 3
þBCG
þHepa B at Birth
24hours- 7days
þRotavirus
þOPV
þIPV
þPentavalent
þPCV13
þAMV( Measles)
þMMR
þOTHERS
FIC: __Yes Date: __________________ __No CIC: __Yes Date: ______________ __No
NUTRITION
EXCLUSIVE BREASTFEEDING MONTHLY MONITORING
1MOTH 2 MONTHS 3 MONTHS 4 MONTHS 5MONTHS 6MONTHS REMARKS
__YES __NO __YES __NO __YES __NO __YES __NO Y / N Y / N
MEDICAL SERVICES
Physical Findings
DATE AGE Complaints Interventions Remarks
Weight Height Temp
