NAME: __________________________________________________________ DATE: __________________________

Republic of the Philippines

Province of Sultan Kudarat
SULTAN KUDARAT DISTRICT HOSPITAL
Kinudalan, Lebak, Sultan Kudarat
HEALTH SCREENING and ASSESSMENT FORM
Medical and Surgical History
*PAST MEDICAL HISTORY
Allergy
Specify Allergy: _______________________________________________________
Asthma
Cancer
Specify organ with cancer: ______________________________________________
Cerebrovascular Disease
Coronary
Specify hepatitis type: _________________________________________________
Artery Disease
Diabetes Milletus
Highest blood pressure: __________ / __________mmHg
Emphysema
Epilepsy/Seizure Disorder Specify Pulmonary
_________________________________________________
Hepatitis Tuberculosis category:
Hyperlipidem Specify Extraulmonary
_________________________________________________
Hypertension Tuberculosis category:
Peptic Ulcer
Others, please specify: ___________________________________________________
Pneumonia
Thyroid Disease
Pulmonary Tuberculosis
Extapulmonary Tuberculosis
Urinary Tract Infection
Mental Illness
Others
None
*PAST SURGICAL HISTORY
OPERATION DATE

Family & Personal History

*FAMILY HISTORY
Allergy
Specify Allergy: _______________________________________________________
Asthma
Cancer
Specify organ with cancer: ______________________________________________
Cerebrovascular Disease
Coronary Artery Disease Specify hepatitis type: _________________________________________________
Diabetes Milletus
Highest blood pressure: __________ / __________mmHg
Emphysema
Epilepsy/Seizure Disorder Specify Pulmonary
_________________________________________________
Hepatitis Tuberculosis category:
Hyperlipidem Specify Extraulmonary
_________________________________________________
Hypertension Tuberculosis category:
Peptic Ulcer
Others, please specify: ___________________________________________________
Pneumonia
Thyroid Disease
Pulmonary Tuberculosis
Extrapulmonary Tuberculosis
Urinary Tract Infection
 Mental Illness
Others
None
*PERSONAL/SOCIAL HISTORY
*Smoking
No. of packs/year? ________________________________________________________
Yes No Quit
*Alcohol
No. of bottles/day? ________________________________________________________
Yes No Quit
*Illicit Drugs Sexually Active
*Sexual History Screening
Yes No Yes No

IMMUNIZATION
FOR CHILDREN
BCG
OPV1
OPV2
OPV3
DPT 1
DPT 2
DPT 3
Measles
Hepatitis B1
Hepatitis B2
Hepatitis B3
Hepatitis A
Varicella (Chicken Pox)
None
FOR ADULT
HPV
MMR
None
FOR PREGNANT
Tetanus Toxoid
None
FOR ELDERLY AND IMMUNOCOMPROMISED
Pnuemococcal Vaccine
Flu Vaccine
None
OTHERS, PLEASE SPECIFY

OB-Gyne History
FAMILY PLANNING
with access to family planning counselling?
Yes No
MENSTRUAL HISTORY Applicable Not Applicable
Menarche: _________ yrs. old Onset of sexual intercourse:__________ yrs. old Menopause? Yes No
 If yes, what age? ___________ yrs. old
Last menstrual period: ________________ (mm/dd/yyyy) Birth control method: _________________
Period duration: ________ days Interval cycle: ________ days
No. of pads/day during menstruation: ______________
PREGNANCY HISTORY Applicable Not Applicable
Gravidity (no. of pregnancy): __________ Parity (no. of delivery):_________ Type of delivery: _______________________
No. of full term: ___________ No. of premature: __________ No. of abortion: ____________ No. of living children: _____________
Pregnancy-induced hypertension (Pre-eclampsia)

PERTINENT PHYSICAL EXAMINATION FINDINGS

*Blood Pressure: ________ /_________ mmHg *Height: _________ (cm) _________ (In)
*Heart Rate: ________ / min *Weight: _________ (kg) ________ (lb)
*Respiratory Rate: __________/ min *BMI: _________________
Visual Aculty: ________ / ________ *Temperature: ____________ ◦c
Pediatric Client aged 0-24 months
Length: __________ (cm) Head Circumference: ___________ (cm) Skinfold Thickness: ___________ (cm)
Body Circumference:
Waist: ___________ (cm) Hip: ___________(cm) Limbs: ___________ (cm)
Middle and Upper Arm Circumference: __________ (cm)
Pediatric Client aged 0-60 months
Z-Score: ___________ (cm)
Blood Type
A+ B+ AB+ O+ A- B- AB- O-
General Survey: Awake and Alert Altered Sensorium
Pertinent Findings Per System
A. HEENT F. DIGITAL RECTAL EXAMINATION
Essentially Normal Essentially Normal
Abnormal pupillary reaction Enlarge Prostate
Cervical lympadenopathy Mass
Dry mucous membrane Hemorrhoids
Icteric sclerae Pus
Pale conjunctivae Not Applicable
Sunken eyeballs Others _______________________________________
Sunken fontanelle
Others _______________________________________________

B. CHEST/BREAST/LUNGS G. SKIN/EXTREMITIES
Essentially Normal Essentially Normal Poor skin turgor
Asymmetrical chest expansion Clubbing Rashes/Petechiae
Decreased breath sound Cold clammy Weak pulses
Wheezes Cyanosis/mottled skin
Lumps over breast(s) Edema/swelling
Crackles/rales Decreased mobility
Retractions Pale nailbeds
Others ______________________________________________ Others _______________________________________

C. HEART H. NEUROLOGICAL EXAMINATION

Essentially Normal Essentially Normal Poor coordination
Displaced apex beat Abnormal gait
Heaves/trills Abnormal position sense
irregular rhythm Abnormal sensation
 Muffled heart sounds Abnormal reflex(s)
Murmurs Poor/altered memory
Pericardial bulge Poor muscle tone/strength
Others ____________________________________________ Others _______________________________________

D. ABDOMEN
Essentially Normal
Abdominal rigidity Others ____________________________________________
Abdominal tenderness
Hyperative bowel sounds
Palpable mass(es)
Tympanitic/dull abdomen
Uterine contraction

E. GENITOURINARY
Essentially Normal
Blood stained in exam finger
Cervical dilatation
Presence of abnormal discharge
Others __________________________________________________________

NCD HIGH-RISK ASSESSMENT

NCD HIGH-RISK ASSESSMENT(for 5 years old and above)
High Fat/High Salth Food Intake
Eats processed/fast food (eg. Instant noodles, hamburgers, fries, fried chickn skin etc.) and ihaw-ihaw (eg. Isaw, adidas, etc.) weekly
Yes No
Dietary Fiber Intake
3 Serving vegetables daily
Yes No
2-3 serving of fruits daily
Yes No

Physical Activities
Does at least 2.5 hours a week of moderate-intensity physical activity
Yes No

Presence or absence of Diabetes

1. Was patient diagnosed as having diabetes?
Yes No Do Not Know
If YES,
With Medication Without Medication
and perform Urine Test for Ketones. If No or Do not Know, proceed to question 2.
2. Does patient have the following symptoms?
Polyphagia Yes No
Polydipsia Yes No
Polyuria Yes No
If two or more of the above symptoms are present, perform a blodd glucose test.
Raised Blood Glucose
Yes No
FBS/RBS Date Taken
mg/dl (mm/dd/yyyy)
mmol/L
Raised Blood Lipids
Yes No
Total Cholesterol _____________________ Date Taken
Presence of Urine Ketones (mm/dd/yyyy)
Yes No
Urine Ketone _______________________ Date Taken
Presence of Urine Protein (mm/dd/yyyy)
Yes No
Urine Protein _______________________ Date Taken
(mm/dd/yyyy)

Questionaire to Determine Probable Angina, Heart, Stroke or Transient Ischemic Attack

Angina or Heart Attack
Yes No
1. Have you had any pain or discomfort or any pressure or heaviness in your chest?
Yes No If NO, go to question 8
2. Do you get the pain in the center of the chest or left arm?
Yes No If NO, go to question 8
3. Do you get it when you walk uphill or hurry?
Yes No
4. Do you slowdown if you get the pain while walking ?
Yes No
5. Does the pain go away if you stand still or if you take a tablet under the toungue?
Yes No
6. Does the pain away in less than 10 minutes?
Yes No
7. Have you ever had a severe chest pain across the front of your chest lasting for half an hour or more ?
Yes No

If the answer to Question 3 or 4 or 5 or 6or 7 is Yes. Patienthave angina or heart attack and needs to see the doctor

Stroke and TIA (Transient Ischemic Attack)

Yes No
8. have you ever had any of the following: difficulty in talking, weakness of arm and/or leg on the side of the body or numbness on one side of the body?
Yes No
If the answer to question 8 is YES, the patient may have had a TIA or stroke and needs to see the doctor.

RISK LEVEL
<10% ✘ 10% to < 20% 20% to < 30% > 40%

Patient's Signature over Printed Name

MOBILE NO.:_____________________________
NAME: ________________________________________________________ DATE: _____________________
Republic of the Philippines
Province of Sultan Kudarat
SULTAN KUDARAT DISTRICT HOSPITAL
Kinudalan, Lebak, Sultan Kudarat
CONSULTATION FORM
SUBJECTIVE/HISTORY OF ILLNESS
*A. CHIEF COMPLAINT
Abdominal Cramp/Pain Hemoptysis
Altered Merntal Sensorium Irritability
Anorexia Jaundice
Bleeding Gums Lower Extremity Edema
Blurring of vision Myalgia
Body Weakness Orthopnea
Chest Pain/Discomfort Pain
Constipation Palpitation
Cough Seizures
Diarrhea Skin Rashes
Dizziness Stool, Blood/Black Tarry/Mucoid
Dysphagia Sweating
Dyspnea Urgency
Dysuria Vomiting/Nausea
Epistaxis Weight Loss
Fever Others
Frequency of Urination
Headache
Hematemesis
Hematuria
*HISTORY OF ILLNESS

OBJECTIVE /PHYSICAL EXAMINATION

*Blood Pressure: *Height: (cm)
/ (mmHg) (inch)

*Heart Rate: (/min) *Weight: (kg)

*Respiratory Rate: (/min) (lb)

*Visual Acuity: *BMI:

*Temperature: (◦C)
PEDIATRIC CLIENT AGED 0-24 MONTHS
Length: Head Circumference: (cm)
(cm)
Body Circmuference: Skinfold Thickness: (cm)
Waist:
(cm) Hip: (cm)
Middle and Upper Arm Circumference:
(cm) Libs: (cm)

Pertinent Findings Per System

A. HEENT F. DIGITAL RECTAL EXAMINATION
Essentially Normal Essentially Normal
Abnormal pupillary reaction Enlarge Prostate
Cervical lympadenopathy Mass
Dry mucous membrane Hemorrhoids
Icteric sclerae Pus
Pale conjunctivae Not Applicable
Sunken eyeballs Others _______________________________________
Sunken fontanelle
Others _______________________________________________

B. CHEST/BREAST/LUNGS G. SKIN/EXTREMITIES
Essentially Normal Essentially Normal Poor skin turgor
Asymmetrical chest expansi Clubbing Rashes/Petechiae
Decreased breath sound Cold clammy Weak pulses
Wheezes Cyanosis/mottled skin
Lumps over breast(s) Edema/swelling
Crackles/rales Decreased mobility
Retractions Pale nailbeds
Others ___________________________________________ Others _______________________________________

C. HEART H. NEUROLOGICAL EXAMINATION

Essentially Normal Essentially Normal Poor coordination
Displaced apex beat Abnormal gait
Heaves/trills Abnormal position sense
irregular rhythm Abnormal sensation
Muffled heart sounds Abnormal reflex(s)
Murmurs Poor/altered memory
Pericardial bulge Poor muscle tone/strength
Others ___________________________________________ Others _______________________________________

D. ABDOMEN
Essentially Normal
Abdominal rigidity Others ____________________________________________
Abdominal tenderness
 Hyperative bowel sounds
Palpable mass(es)
Tympanitic/dull abdomen
Uterine contraction

E. GENITOURINARY
Essentially Normal
Blood stained in exam finge
Cervical dilatation
Presence of abnormal discharge
Others __________________________________________________________

ASSESSMENT/DIAGNOSIS
*Diagnosis:

No. Diagnosis Name:

PLAN/MANAGEMENT
A. *Laboratory/Imaging Examination
Laboratory Imaging Doctor Recommendation Client
Random Blood Sugar Yes No Deselect Yes No Deselect
CBC with platelet count* Yes No Deselect Yes No Deselect
Chest X-ray* Yes No Deselect Yes No Deselect
Creatine Yes No Deselect Yes No Deselect
Electrocardiogram (ECG) Yes No Deselect Yes No Deselect
Fasting Blood Sugar Yes No Deselect Yes No Deselect
Fecal Occult Blood Yes No Deselect Yes No Deselect
Fecalysis Yes No Deselect Yes No Deselect
HbA1c Yes No Deselect Yes No Deselect
Lipid Profile Yes No Deselect Yes No Deselect
Oral Glucose Tolerance Test Yes No Deselect Yes No Deselect
Pap Smear * Yes No Deselect Yes No Deselect
PPD Test (Tuberculosis) Yes No Deselect Yes No Deselect
Sputum Microscopy Yes No Deselect Yes No Deselect
Urinalysis* Yes No Deselect Yes No Deselect
Others:
Asterisk (*) refers to the services recommended by the Guidelines
(AO No. 2017-0012. Guidelines on the Adoptions of Baseline Primary Health Care Guarantee for All Filipinos)

"Deselect option is added to unselect/uncheck the checked option in Doctor Recommendation and Client Request or Refuse to avoid reloading of the page

B. *MANAGEMENT (check if done) Not Applicable

Breastfeeding Program Education
Counselling for Smoking Ce
Counselling for Lifestyle Mo
Oral Check-up and Prophylaxis
Others

C. *PRESCRIBE MEDICINE/S With prescribe drug/medicine No Medicine Prescribe

Prescibing Physician: Is Drug/Medicine dispensed?: Dispensing Personnel
✘ Yes No
NAME OF PRESCRIBING PHYSICIAN
Dispense Date: _____________________

Drug/Medicine
Drug/Medicine (Completed Details)
Generic Name Salt Strenght Form Unit Package

Other Drug/Medicine (If not available in the list of library) Drug Grouping Quantity Actual Unit Price

A. ADVICE
Medicine Instruction
Quantity Strength Frequency

Remarks:
Attending Physician
e page