Family Serial No.

Annex 2.6 Republic of the Philippines

Department of Health

FAMILY PLANNING SERVICE RECORD* SIDE A

MEDICAL HISTORY PHYSICAL EXAMINATION
3 Z Z Z 0
HEENT Blood Pressure: mm Weight kg/lbs m 0 P. > '-
❑ Epilepsy/Convulsion/Seizure 0 Enlarged thyroid Pulse Rate: / min (N.V. = 70 to80/min) -I 3 3 r71
i 0 m m Z
❑ Severe headache/dizziness ❑ Yellowish
CONJUNCTIVA
0 m o o -1
❑ Visual disturbance/ conjunctiva 0 r 71 71 Z
blurring of vision Pale ❑Yellowish
-
<
0 n 0
D -0 1- :.
NECK (1 E C0 r71
CHEST/HEART n c)
z
❑ Severe chest pain ❑ Enlarged thyroid m
-
,, VI
!II _1
“
❑ Shortness of breath and easy fatigability ❑ Enlarged lymph nodes -I I
m F -1

0
BREAST 0

ED
❑ Breast/axillary masses Right Breast Left Breast CJ 73 -<

r
❑ Nipple discharges (specify if blood or pus) ❑ Mass -• m -o
❑ Systolic of 140 & above ❑ Nipple discharge Z m
m
❑
El
Diastolic of 90 & above
Family history of CVA (strokes), hypertension asthma,
❑ Skin - orange peel or dimpling
i 1 A

.
rheumatic hearth disease
❑ Enlarged axillary lymph nodes z z n
THORAX 1:1 > > m
r a 3 -I
❑ Abnormal heart sounds/cardiac rate D rrl m
ABDOMEN Z 0

,
❑ Abnormal breath sounds/respiratory rate ??
❑ Mass in the abdomen 3
ABDOMEN ❑
❑ History of gallbladder disease
El History of liver disease El Enlarged lever CI Mass Mj
n Z
GENITAL ❑ Tenderness I
0 ,-.
❑ Mass in the uterus ❑ Intermenstrual bleeding EXTREMITIES (-) F 0 CI
7 o
0
❑ Vaginal discharge ❑ Postcoital bleeding ❑ Edema E Varicosities n Xm mZ Z =
o
o
=
■-, -- > > a
EXTREMITIES PELVIC EXAMINATION ❑ 3 3 c9,
'A m P,
' m 3
CI Severe varicosities Others - (Please specify) -o -<
❑ Swelling or severe pain in the legs not related to injuries PERINEUM co (D
7,
F+
,

0
-o

SKIN UTERUS it, " -... E

❑ Scars
Position n 0 ---
n
❑ Yellowish skin
❑ Warts
50- z ....., o
❑ Mid rT o Z
HISTORY OF ANY OF THE FOLLOWING -... ?.,
❑ Reddish ❑ 5'
❑ Smoking ❑ Anteflexed
El Laceration C) ;:i ij 0 g'
❑ Allergies '1 Retroflexed o m > > c'' '
VAGINA m > ...1 m C
❑ Drug intake (anti-tuberculosis, anti-diabetic, anticonvulsant)
Size ci. 0 m
0 Congested o 0 0 9,
3
❑ Bleeding tendencies (nose, gums, etc.) ❑ Bartholin's cyst ❑ Normal ❑El Z -n 027, 1:1
❑ Anemia ❑ Small 11 co -1 as
❑ Diabetes El Warts E 0 71 i m
❑ Large 0 x -I — <
❑ Skene's Gland -1, s3___ c0
>
Discharge Mass ❑ °
OBSTERICAL HISTORY (xi n 8: ra U1
El Rectocele Uterine Depth: cms. H 1 -'<' -$_. r
❑ Number of pregnancies: R ..-.-e -, -‹
❑ Cystocele (for intended IUD users) - ?) e C

Full Term Premature CERVIX Z , Z.'.- 0

Abortions Living Children < CI m
Full Term ❑ Congested ADNEXA v) m >GI 0
n :I? 3
❑ Date of last delivery / / L❑ Erosion
Mass m m
0 —I
❑ Type of last delivery ❑ Discharge ❑ I I
❑ Past menstrual period
Tenderness Tc) 0
El Polyps/cysts Z I
❑ Last menstrual period m P
El Laceration 0❑ 1
El Duration and character Consistency
Menstrual bleeding
v)
0
m +,
LL Firm c L'
RISKS FOR VIOLENCE AGAINST WOMEN ( \WA,f) X n H
❑ > ra
El History of domestic violence or VAW o:1 < c
oo m n
HISTORY OF ANY OF THE FOLLOWING ❑ Unpleasant relationship with partner -I 73
D
❑ Hydatidiform mole (within the last 12 months) ❑
❑ Partner does not approve of the visit to FP clinic C/m 0
❑ Ectopic pregnancy co- , 3 n
STI RISKS ❑ Partner disagrees to use FP = ,._., r, c
❑ With history of multiple partners
Referred to: o DSWD ❑ WCPU ❑ NGOs z
Oa
n - >
❑ Others (specify: ) ,, 0 Z 1H 0
For Women: C I >
ACKNOWLEDGEMENT: ES v- m
> _<
m
m
-1
❑ Unusual discharge from vagina This is to certify that the Physician/Nurse/ Midwife of the PI' 0 - Z -1
❑ Itching or sores in or around vagina P) Z Z o 3
❑ Pain or burning sensation clinic has fully
❑ Treated for
explained to me the
❑ Treated for STIs in the past different
STIs in the past methods
For Men: available in family
❑ Pain or burning sensation
Swollen planning and I freely
choose the
testicles or m
❑ Open sores anywhere in genital area
penis
❑ Pus coming from penis
❑ Client Signature
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c
p7,. n C
Z
n
0 0 (4 m
3 -0
c
o z
fD
m w
-< C3
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<0 &
S Z
Reminder: Kindly refer to PHYSICIAN for any checked (V) findings prior to provision of any method for furtherraluation.