Republic of the Philippines

Department of Health

DOH MAINTENANCE MEDICINES UTILIZATION REPORT

Health Facility:_____________
Report Year: _______
Report Month:_______

MEDICATIONS GIVEN
(Indicate the number of treatment
DATE/ BHW

DATE PHILHEALTH packs dispensed)

GENDER
NO.
RECEIVED BY:
NAME OF PATIENT OF

METOPROLOL

SIMVASTATIN
ADDRESS AGE/ (Signature over

LOSARTAN 50
AMLODIPINE

MG 30 Tablets

METFORMIN

GLICLAZIDE
30 MG MR 30
(Last Name, First Name, Middle Name) BIRTH (If PhilHealth

500 MG 90
Tablets TP

Tablets TP

Tablets TP

Tablets TP

Tablets TP
10 MG 30

50 MG 60

20 MG 30
CS member) printed name)

TP
AGU MABINI, CAR. 70
A ABRAHAM SAMBRANO 04-30-48 F - /
ADORACION CAT. M
AGU MABINI, CAR. 57
A DELOS SANTOS DANTE SALVIDAR 08-06-61 M - / CAPTOPRIL
CAT. M
AGU MABINI, CAR. 58
A ZUNIEGA ELMA VILLEGAS 03-24-60 F - / /
CAT. w
AGU MABINI, CAR.
A SALVIDAR LITA DE LEON 68 07-30-50 F - / /
CAT. W
BELE MABINI, CAR. 46
N ALEGRE ALONA MERANDILLA 07-18-72 F - */
CAT. s
BELE MABINI, CAR. 56
N DALMINO SUSAN ALEGRE 02-28-62 F - */
CAT. M
MABINI, CAR. F
TRAQUENA BELHICA SAMOSA
CAT. */
AGU MABINI, CAR. 68
A DE MESA ARACELI ONAN 12-12-50 F 102027418829 / /
CAT. M
ABL MABINI, CAR. 78
E PARONE VIRGINIA ZUNIEGA S 02-08-40 F - */
CAT.
ABL MABINI, CAR. 74
E DELA CRUZ ADELFA PARONE M 12-12-44 F - */ CAPTOPRIL
CAT.
ABL MABINI, CAR. 64
E BALMES MERLITA DELOS SANTOS M 1-05-54 F - /
CAT.
ABL MABINI, CAR. 85
E ABLE FELIZA SAPICO W 03-08-38 F - /
CAT.
YUT MABINI, CAR. 84
AN DELA ROSA LERMA VILLEGAS M 11-02-63 F - /
CAT.
TRIN MABINI, CAR.
I DIZON ESTEBAN NOGALES M 05-20-34 M 102020908847 /
CAT.
 Republic of the Philippines
Department of Health

DOH MAINTENANCE MEDICINES UTILIZATION REPORT

Health Facility:_____________
Report Year: _______
Report Month:_______

MEDICATIONS GIVEN
(Indicate the number of treatment
DATE PHILHEALTH packs dispensed)

GENDER
RECEIVED BY:
DATE

NAME OF PATIENT OF NO.

METOPROLOL

SIMVASTATIN
ADDRESS AGE/ (Signature over

LOSARTAN 50
AMLODIPINE

MG 30 Tablets

METFORMIN

GLICLAZIDE
30 MG MR 30
(Last Name, First Name, Middle Name) BIRTH (If PhilHealth

500 MG 90
Tablets TP

Tablets TP

Tablets TP

Tablets TP

Tablets TP
10 MG 30

50 MG 60

20 MG 30
CS member) printed name)

TP
WAR MABINI, CAR. 50
YUTAN DALIPE 04-23-68 M - */
LEVI CAT. M
MABINI, CAR. 65
YUTAN ASUNCION FRANCISCO W 05-25-53 F - / /
CAT.
MABINI, CAR. F
YUSORES ELISA DELOS SANTOS
CAT. */
BALM MABINI, CAR. 46
ES SAMONTE ROSITA FERNANDEZ M 09-08-72 F - /
CAT.
BALM MABINI, CAR. 50
ES ONAN FRANCISCA DIZON M 10-04-68 F - /
CAT.
AGUA MABINI, CAR. 76
SAPICO CRISTITA BALMES 02-02-42 F - /
CAT. W
MABINI, CAR. M
DALIPE NOLI YUBO
CAT. /
BELD MABINI, CAR. 47
A DALIPE JOSECERO ROJAS M 04-02-71 M 4PS */
CAT.
EDE MABINI, CAR. 73
BERMEJO NEIVES VILLAMOR S 11-25-45 F - /
CAT.
MABINI, CAR. F
MENDEZ ASUNCION
CAT. /
ABLE MABINI, CAR. 64
DEL AGUA ANITA SALVIDAR M 06-12-54 F - /
CAT.
BALM MABINI, CAR. 77
ES CIPRIANO GLORIA DELOS SANTOS M 02-12044 F 102020922408 /
CAT.
BALM MABINI, CAR. 67
ES SAMONTE MELBA DELOS SANTOS 05-18-51 F - /
CAT. M
EDE MABINI, CAR. 67
TOLIN EVELYN ALMARIO M 03-27-51 F - /
CAT.
 Republic of the Philippines
Department of Health

DOH MAINTENANCE MEDICINES UTILIZATION REPORT

Health Facility:_____________
Report Year: _______
Report Month:_______

MEDICATIONS GIVEN
(Indicate the number of treatment
DATE PHILHEALTH packs dispensed)

GENDER
RECEIVED BY:
DATE

NAME OF PATIENT OF NO.

METOPROLOL

SIMVASTATIN
ADDRESS AGE/ (Signature over

LOSARTAN 50
AMLODIPINE

MG 30 Tablets

METFORMIN

GLICLAZIDE
30 MG MR 30
(Last Name, First Name, Middle Name) BIRTH (If PhilHealth

500 MG 90
Tablets TP

Tablets TP

Tablets TP

Tablets TP

Tablets TP
10 MG 30

50 MG 60

20 MG 30
CS member) printed name)

TP
BALM MABINI, CAR. 62
ES TARROQUIN VITO M 11-26-56 F 102025623883 /
MYRNA CAT.
BALM MABINI, CAR. 75
ES PARES ANTONIA GALICIA W 05-04-43 F - /
CAT.
MABINI, CAR. F
PANTI ELENITA YUTAN
CAT. /
MABINI, CAR. F
FERNANDEZ ELENITA MARTINEZ
CAT. /
EDE MABINI, CAR. 72
BATALIA MARIA BERMEJO M 04-12-46 F - /
CAT.
EDE MABINI, CAR. 67
EVANGELISTA PEDRO INDICO M 12-31-51 M - / /
CAT.
BELD MABINI, CAR. 60
A DALIPE ELENA SAMOSA W 02-18-58 F - /
CAT.
ABLE MABINI, CAR. 71
ONAN LOLITO DELA ROSA M 01-14-47 M - /
CAT.
MABINI, CAR. 52
CORTUNA NINA SAPICO M 09-01-66 F - /
CAT.
YUTA MABINI, CAR. 45
N ALARCON RUTH ABRAHAM M 05-06-73 F 102015650602 /
CAT.
BONG MABINI, CAR. 56
ON CANICULA SOLEDAD POLIDO M 12-11-62 F - / ASPIRIN
CAT.
MABINI, CAR. 40
DELOS SANTOS LEA FERNANDEZ S 08-25-78 F - */
CAT.
MABINI, CAR. 44
MERABEL MERLY FERNANDEZ M 06-14-74 F - */ */
CAT.
EDE MABINI, CAR. 54
BATALIA SONIA CLOREZ M 10-08-64 F 102020918362 / /
CAT.
Republic of the Philippines
 Department of Health

DOH MAINTENANCE MEDICINES UTILIZATION REPORT

Health Facility:_____________
Report Year: _______
Report Month:_______

MEDICATIONS GIVEN
(Indicate the number of treatment
DATE/BHW

DATE PHILHEALTH packs dispensed)

GENDER
OF NO.
RECEIVED BY:
NAME OF PATIENT

METOPROLOL

SIMVASTATIN
ADDRESS AGE/ (Signature over

LOSARTAN 50
AMLODIPINE

MG 30 Tablets

METFORMIN

GLICLAZIDE
30 MG MR 30
(Last Name, First Name, Middle Name) BIRTH (If PhilHealth

500 MG 90
Tablets TP

Tablets TP

Tablets TP

Tablets TP

Tablets TP
10 MG 30

50 MG 60

20 MG 30
CS member) printed name)

TP
MABINI, CAR. 74
AGUILAR TABUZO 12-07-44 M 102000075164 /
GERONIMO CAT. M
BELE MABINI, CAR. 85
N IBARDALOZA LOURDES CETORICO 03-30-33 F - /
CAT. M
BELE MABINI, CAR. 42
N BRADECINA ROWENA CORDONEZ 03-16-76 F - */ */
CAT. M
EUB MABINI, CAR. 56
RA PANZA SALVADOR DALIPE M 04-28-62 M - */ */
CAT.
MABINI, CAR. 47
BALBUENA MARITES VALLESPIN M 10-27-71 F - / /
CAT.
MABINI, CAR. M
DE LEON RODULFO BALBUENA
CAT. /
YUT MABINI, CAR. 79
AN PANCHO MARCELA DELA ROSA W 08-10-39 F - /
CAT.
BAL MABINI, CAR. 88
MES SALES MAGDALENA BALMES W 05-28-30 F 102026261608 /
CAT.
BEL MABINI, CAR. 47
DA BIBON HAYNA AGUILAR M 02-24-71 F - /
CAT.
ABL MABINI, CAR. 65
E BALMES RAYMUNDA BASA M 11-27-53 F - /
CAT.
WAR MABINI, CAR. 64
DEL AGUA MENCHITA SAPICO 08-15-54 F - / /
CAT. M
BAL MABINI, CAR. 65
MES FERNANDEZ LAURA DELA ROSA M 05-27-53 F - /
CAT.
MABINI, CAR. 74
EUBRA ANGELINA W 11-01-44 F - /
CAT.
MABINI, CAR. 49
TAPIA MARIA VILLEGAS M 07-07-69 F - / /
CAT.
Republic of the Philippines
 Department of Health

DOH MAINTENANCE MEDICINES UTILIZATION REPORT

Health Facility:_____________
Report Year: _______
Report Month:_______

MEDICATIONS GIVEN
(Indicate the number of treatment
DATE/BHW

DATE PHILHEALTH packs dispensed)

GENDER
OF NO.
RECEIVED BY:
NAME OF PATIENT

METOPROLOL

SIMVASTATIN
ADDRESS AGE/ (Signature over

LOSARTAN 50
AMLODIPINE

MG 30 Tablets

METFORMIN

GLICLAZIDE
30 MG MR 30
(Last Name, First Name, Middle Name) BIRTH (If PhilHealth

500 MG 90
Tablets TP

Tablets TP

Tablets TP

Tablets TP

Tablets TP
10 MG 30

50 MG 60

20 MG 30
CS member) printed name)

TP
BEL MABINI, CAR. 64
DA COLAMBO AGUILAR M 12-13-54 M - /
RODULFO CAT.
EUB MABINI, CAR. 70
RA DE QUIROZ ADELA ONAN W 11-03-48 F - /
CAT.
ABL MABINI, CAR. 66
E BALMES BONIFACIO YUSORES M 05-14-52 M - /
CAT.
WAR MABINI, CAR. 53
SALVIDAR SALVACION MAGTANGOB W 12-03-65 F GOVT /
CAT.
WAR MABINI, CAR. 50
TRINIDAD MARITEL SALVADOR M 07-04-68 F 102020900846 /
CAT.
TRIN MABINI, CAR. 47
I ASANZA MARIVIC SALVIDAR M 10-20-71 F - /
CAT.

EUB MABINI, CAR. 52

RA PANZA EVELINDA BAYAS M 07-29-66 F - /
CAT.
WAR MABINI, CAR. 56
DEL AGUA NERIE BIBON M 05-26-62 F - /
CAT.
TRIN MABINI, CAR. 41
I AGUILAR JOSEPHINE W 07-04-70 F /
CAT.
BON MABINI, CAR. 52
GON CANICULA LAIDA ALINO M 12-25-66 F 102025624499 /
CAT.
ABL MABINI, CAR. 54
E TARROQUIN ADELINA ONAN M 01-15-64 F - /
CAT.
WAR MABINI, CAR. 44
VALLESPIN LUCY ARCILLA 08-09-74 F /
CAT. F
BELE MABINI, CAR. 39
N DEL AGUA VILMA BOBIER M 09-21-79 F 230006903822 /
CAT.

Republic of the Philippines

 Department of Health

DOH MAINTENANCE MEDICINES UTILIZATION REPORT

Health Facility:_____________
Report Year: _______
Report Month:_______

MEDICATIONS GIVEN
(Indicate the number of treatment
DATE/BHW

DATE PHILHEALTH packs dispensed)

GENDER
OF NO.
RECEIVED BY:
NAME OF PATIENT

METOPROLOL

SIMVASTATIN
ADDRESS AGE/ (Signature over

LOSARTAN 50
AMLODIPINE

MG 30 Tablets

METFORMIN

GLICLAZIDE
30 MG MR 30
(Last Name, First Name, Middle Name) BIRTH (If PhilHealth

500 MG 90
Tablets TP

Tablets TP

Tablets TP

Tablets TP

Tablets TP
10 MG 30

50 MG 60

20 MG 30
CS member) printed name)

TP
AGUA MABINI, CAR. COHAB
ZUNIEGA ABRAHAM 63 07-02-55
M 102000077450 /
CAT.
AMADEO
BALM MABINI, CAR. 46
ES SAMONTE OFELIA OBANG M 04-04-72 F 102026239785 /
CAT.
BALM MABINI, CAR. 52
ES ONAN FERDINAND AGUILAR M 04-29- M - /
CAT.
EUBR MABINI, CAR. 74
A FLORES JIMMY VILEATE S 02-08-44 M - /
CAT.
BELE MABINI, CAR. 80
N DELOS SANTOS JUAN PEREYRA M 08-09-38 M - /
CAT.
AGUA MABINI, CAR. 63
INDICO ANITA SALVIDAR W 10-24-55 F /
CAT.
BALM MABINI, CAR. 64
ES CLAVANO HELEN DELOS SANTOS M 01-03-56 F - /
CAT.
AGUA MABINI, CAR. 58
ZUNIEGA ELMA VILLEGAS W 03-24-60 F - / /
CAT.
BONG MABINI, CAR. 67
ON ISUELA ELICITA SAPICO W 03-22-51 F - / /
CAT.
BALM MABINI, CAR. 60
ES SAMBRANO WILFREDO AGUILAR M 11-25-58 M 4PS /
CAT.
ABLE MABINI, CAR. 71
DEL AGUA ORBEL ARCILLA M 10-17-47 M - / /
CAT.
EDE MABINI, CAR. 57
ANDINO FLORENCIO CANICULA S 02-23-61 M - /
CAT.

Republic of the Philippines

 Department of Health

DOH MAINTENANCE MEDICINES UTILIZATION REPORT

Health Facility:_____________
Report Year: _______
Report Month:_______

MEDICATIONS GIVEN
(Indicate the number of treatment
DATE/BHW

DATE PHILHEALTH packs dispensed)

GENDER
OF NO.
RECEIVED BY:
NAME OF PATIENT

METOPROLOL

SIMVASTATIN
ADDRESS AGE/ (Signature over

LOSARTAN 50
AMLODIPINE

MG 30 Tablets

METFORMIN

GLICLAZIDE
30 MG MR 30
(Last Name, First Name, Middle Name) BIRTH (If PhilHealth

500 MG 90
Tablets TP

Tablets TP

Tablets TP

Tablets TP

Tablets TP
10 MG 30

50 MG 60

20 MG 30
CS member) printed name)

TP
AGUA MABINI, CAR. 39
ABRAHAM TUPLANO M 12-05-79 F 4PS /
JHODELYN CAT.
ABLE MABINI, CAR. 65
BALMES RAYMUNDA BASA W 11-27-53 F - /
CAT.
 Republic of the Philippines
Department of Health

PERSON WITH DISABILITY REGISTRY

Health Facility:_____________
Report Year: _______
Report Month:_______

TYPE OF DISABILITY
DATE/BHW

DATE PHILHEALTH

GENDER
SERVICES

PSYCHOSOCIA
NO.

L DISABILUTY

AND OTHERS)
CANCER, HPN

ORTHOPEDIC
OF

IMPAIRMENT
NAME OF PATIENT

DISABILITY

DISABILITY

DISABILITY

DISABILITY

DISABILITY
LEARNING
ADDRESS AGE/ PROVIDE

CHRONIC
HEARING

(STROKE,
MENTAL

ILLNESS

SPEECH
VISUAL
(Last Name, First Name, Middle Name) BIRTH (If PhilHealth
CS member) D

MABINI, CAR. F
SOLSONA REAZON
CAT. 01-26-00
TRINA
MABINI, CAR. F
TUPLANO MARY JANE TRAQUENA 07-15-14
CAT.
MABINI, CAR. F
PANZA JULIET PERDIGON 01-25-69
CAT.
MABINI, CAR. M
PERAGON WENCESLAO BONGON
CAT.
MABINI, CAR. M
ABRAHAM NOEL -
CAT.
MABINI, CAR. M
ABRAHAM JAY DELOS REYES
CAT.
MABINI, CAR. F
ZUNIEGA SOLEDAD ABRAHAM
CAT.
MABINI, CAR. M
BANADERA LEANDRO SALES
CAT.
MAC MABINI, CAR. M
ABRAHAM ZUNIEGA
ALDRICH CAT.
MABINI, CAR. F
PALERO MARINA -
CAT.
MABINI, CAR. F
PANZA EVELYN BAYAS
CAT.
MABINI, CAR. F
DETERALA MARY JANE AGUILAR
CAT.
MABINI, CAR. F
DE QUIROZ ADELA ONAN
CAT.
MABINI, CAR. M
FLORES JIMMY VILEATE
CAT.
MABINI, CAR. M
SAPICO FELIX BALMES
CAT.
 MABINI, CAR.
SAPICO AILA EUSEBIO
CAT.