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    FC - Initial - Annual Health Record

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    Glenda Ang Bacomo
    This document is an initial and annual health record form for a patient. It collects information about the patient's material history during pregnancy including illnesses, type of delivery, place of delivery, complications, allergies, immunization history including dates given for various vaccines, deworming history, and any disabilities or impairments. The form is to be completed by a physician to document the patient's health history.

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    FC - Initial - Annual Health Record

    Uploaded by

    Glenda Ang Bacomo
    30 views2 pages
    This document is an initial and annual health record form for a patient. It collects information about the patient's material history during pregnancy including illnesses, type of delivery, place of delivery, complications, allergies, immunization history including dates given for various vaccines, deworming history, and any disabilities or impairments. The form is to be completed by a physician to document the patient's health history.

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    Fc - Initial _ Annual Health Record

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    This document is an initial and annual health record form for a patient. It collects information about the patient's material history during pregnancy including illnesses, type of delivery, place of delivery, complications, allergies, immunization history including dates given for various vaccines, deworming history, and any disabilities or impairments. The form is to be completed by a physician to document the patient's health history.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as docx, pdf, or txt
    30 views2 pages

    FC - Initial - Annual Health Record

    Uploaded by

    Glenda Ang Bacomo
    This document is an initial and annual health record form for a patient. It collects information about the patient's material history during pregnancy including illnesses, type of delivery, place of delivery, complications, allergies, immunization history including dates given for various vaccines, deworming history, and any disabilities or impairments. The form is to be completed by a physician to document the patient's health history.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as docx, pdf, or txt
    of 2

    INITIAL AND ANNUAL HEALTH RECORD

    (For use of the Physician)

    NAME:

    I. MATERIAL HISTORY: Please check illness/es during pregnancy:


    Goiter German Measles
    Diabetes Hepatitis
    Tuberculosis Sexually Transmitted Disease
    Hearth Diseases Others (Specify)

    II. BRIEF HISTORY


    a. Type of Delivery
    Normal spontaneous Delivery
    Caesarian Section
    Forceps
    b. Place of Delivery
    Hospital
    Home
    Other (Specify)
    c. State complication if any:

    d. Allergies, if Any:

    III. IMMUNIZATION

    DATE’s GIVEN
    st
    1 2nd 3rd
    New Born Screening
    DPT
    POLIO
    BCG
    MEASLES
    TETANUS
    HEPATITIS B
    OTHERS (Specify)

    IV. DEWORMING

    Date of Last Deworming


    YES
    NO

    V. DISABILITY/IMPAIRMENT: PLEASE CHECK IF ANY:

    Congenial deformities Speech defect


    Deafness Emotional disturbances
    Others (Specify)

    MIDWIFE

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