INSTRUCTIONS SAMPLE

PHILHEALTH NO. MEMBER/

LAST_NAME FIRST_NAME MIDDLE_NAME SUFFIX
(PIN) DEPENDENT

00-1234-56789-1 M DE LA CRUZ JUAN MEDINA JR

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BIRTHDAY
CONTACT_NO AGE SEX (M/F) ADDRESS/BRGY
MMDAY/YYY

912345678 07/10/97 26 M BRGY BUKAL

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HEART CLUB SWEETHEART CLUB PWD(IF YES PUT 4PS (IF YES PUT
BLOOD TYPE
Y/N Y/N PWD ID NO.) ID NO.)

N N N N AB

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MENARCH (AGE)
BLOOD HEIGHT FOR WOMEN AGE
HEART RATE RESPIRATORY RATE WEIGHT (KG)
PRESSURE (INCH) OF 1ST DAY OF
PERIOD ARRIVE

120/80 120/80 22 70 170 11

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NO.OF TYPE OF DELIVERY NO.OF NO. OF living

PREGNANCY (NORMAL -CS) MISCARRIAGE children

4 NORMAL 0 2

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VACCINE HISTORY (FOR CHILDREN, ADULT, COVID

VACCINE)

HPV,MMR, HEPA FLU, PNEUMONIA, TETANUS TOXOID,

AZ,SINOVAC,MODERNA,PFIZER ETC.

Note: In this section pls.put only applicable vaccine they

receive.

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MEDICAL HISTORY, HYPERTENSION, DIABETIC (INDICATE IF

OPERATED,PERFORM LAB TEST, PUT RESULT/DIAGNOSIS)

HPN, DM, BREAST CANCER OPERATION, UNDER MEDICATION,

FULLY RECOVERED, UNDERGOING DIALYSIS WITH MAINTENANCE/
CLEAR LAB TESTS

Note: In this section, put only applicable current condition of

patient make sure that their medications are fully supported by
the doctor who examined them. Indicate if with doctors
diagnosis/advise

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REMARKS

TO COME BACK FOR RE-EXAMINATION , FOR

FOLLOW UP MEDICATION

Note: in this section need to put Doctors advise or

their reasons and current situation why they cant
continue medications, or why they cant go to Health
facility to get medical assistance or be checked by
Doctor

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PHILHEALTH NO. MEMBER/
(PIN) DEPENDENT LAST_NAME FIRST_NAME MIDDLE_NAME
 BIRTHDAY
SUFFIX CONTACT_NO MM/DAY/YYYY AGE SEX (M/F)
 HEART CLUB SWEETHEART CLUB PWD(IF YES PUT 4PS (IFYES PUT ID
ADDRESS/BRGY Y/N Y/N PWD ID NO. NO.)
 BLOOD HEIGHT
BLOOD TYPE PRESSURE HEART RATE RESPIRATORY RATE WEIGHT (KG) (INCH)
 NO.OF TYPE OF DELIVERY NO. OF living
MENARCH (AGE) PREGNANCY (NORMAL -CS) children
 MEDICAL HISTORY, HYPERTENSION, DIABETIC
VACCINE HISTORY (FOR CHILDREN, ADULT, COVID
VACCINE) (INDICATE IF OPERATED,PERFORM LAB TEST,
PUT RESULT/DIAGNOSIS)
REMARKS