HOUSEHOLD PROFILE

PHILIPPINE HEALTH AGENDA - FIRST 100 DAYS FORM

RECORDING FORM 1
HOUSEHOLD PROFILE

Date NHTS No.

Visited/Profiled
Province
Mun/City
Brgy

Name of NHTS Member and

Relation Birthday Age Sex PhilHealth Member Remarks
Dependents

(Last, First, Middle Name) M/F Y/N (Phil health no.) etc.
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 TSeKaP Services
Form 1

PHILIPPINE HEALTH AGENDA - FIRST 100 DAYS FORM

RECORDING FORM 1A
NEWBORN 0-28 DAYS

Significant Remarks/Actions
# Name Sex Physical Exam Weight Length Eye Exam Ear Exam
Findings Taken

Y/N kg cm Y/N Y/N

1 M/F

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3
4
5
6
Form 2 TSeKaP Services

PHILIPPINE HEALTH AGENDA - FIRST 100 DAYS FORM

RECORDING FORM 1B
INFANT (29 days - 11 months)

Physical Complete Significant

# Name Sex Exam Length Weight Blood Count Blood Typing Urinalysis Stool Exam Eye Exam Ear Exam Findings Remarks/Actions Taken

M/F Y/N cm kg Y/N Y/N Y/N Y/N Y/N Y/N

5
Form 3 TSeKaP Services

Physical Complete Blood Stool Significant

# Name Urinalysis Eye Exam Ear Exam Oral Services Remarks/Action Taken
Exam Blood Count Typing Exam Findings

Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N

5
 TSeKaP Services
Form 4

Complete Stool
# Name Physical Exam Blood Typing Urinalysis Eye Exam Ear Exam Oral Services Significant Findings Remarks/Actions Taken
Blood Count Exam

Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N

5
Form 5 TSeKaP Services

F TSeKaP Services
# Name M Significant
Complete
Pregnant Post Partum Non-Pregnant Physical Exam Weight Height Blood Pressure Blood Count Blood Typing Urinalysis Fasting Blood Sugar Stool Exam Family Planing Eye Exam Ear Exam Oral Exam Remarks/Actions Taken
Findings
Y/N kg cm Y/N Y/N Y/N Y/N Y/N Y/N w/ Unmet need Counseling Commodities Y/N Y/N Y/N

3
Form 6 TSeKaP Services

F TSeKaP Services
# Name M Blood Complete Blood
Pregnant Post Partum Non-Pregnant Physical Exam Weight Height Pressure Count Blood Typing Urinalysis Fasting Blood Sugar Stool Exam Family Planing

Y/N kg cm Y/N Y/N Y/N Y/N Y/N Y/N w/ Unmet need

3
Form 6 TSeKaP Services

Family Planing

Counseling
Form 7 TSeKaP Services

50 - 59 years old

PHILIPPINE HEALTH AGENDA - FIRST 100 DAYS FORM

RECORDING FORM 1G
50-59 y/o

# Name Sex PE Height Weight BP CBC Blood Typing Blood Sugar Urinalysis Stool Eye Exam Ear Exam Oral Services Significant Findings Remarks/Actions
Test Exam Taken

1 M/F Y/N cm kg Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N

2
3
4
5
6
Form 7 TSeKaP Services

PHILIPPINE HEALTH AGENDA - FIRST 100 DAYS FORM

RECORDING FORM 1H
60 y/o and Above

Blood Sugar Stool Remarks/Actions

# Name Sex PE Height Weight BP CBC Blood Typing Urinalysis Eye Exam Ear Exam Oral Services Significant Findings
Test Exam Taken

M/F Y/N cm kg Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N

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3
4
5