PGH Form No.

Q-660003 PHILIPPINE GENERAL HOSPITAL

The National University Hospital
University of the Philippines Manila
CHILD PROTECTION UNIT

I NTAKE
 353-0667
Taft Avenue, Manila
PHIC–Accredited Health Care Provider
ISO 9001:2008 Certified

Patient’s name  M F Date

DOB and age Born / / _____ years old CPU Case #
Informant Relation
Primary complaint  Physical abuse  Sexual abuse  Neglect
to child
Services sought  Full eval  Physical exam  Interview  Psychiatric eval Socialworker

 Pedia ER  Pedia OPD  Surgery/Trauma  Psychiatry  OB-Gyn  Ortho  Other

Intra-PGH referral from
 Inpatient If inpatient, which ward referred  Pedia  Surgery  Ortho  Psych  ENT  Other
External referral from  DSWD  NBI  PNP  DOJ  Relative  Neighbor  NGO  Physician  self  Other:

PATIENT’S ADDRESS & PRESENT LOCATION

Permanent address Permanent telephone:
Directions to address

barangay #
Present address
 Metro Manila If within Metro Manila, which Municipality/city___________ Present telephone

Directions to address

Present caretaker

Child’s legal status  Legitimate  Illegitimate  Adopted  Unknown Relation to child

Family contact Enrolled in school?  No  Yes, at:
Family address/phone Educational Level
Contact Relation to child

FAMILY COMPOSITION
Relation Lives w/ Age/ Civil Weekly School/ Contact
Name Employed? Occupation Education
to child child? Gender Status Income Company Information

 N Y  N Y  OFW
mother
 father  N Y  N Y  OFW

 N Y  N Y
Siblings
 N Y  N Y
 N Y  N Y
 N Y  N Y
 N Y  N Y
Socio-economic
Status  Low  Middle  Upper # of Children_____ # of individual family members_______ # of families in household______

FOR INCEST CASES ONLY

Regular sleeping arrangement  at home  on the street  in a shelter: __________________________  other:
Same bed/mat with  adult male  adult female  male child(ren)  female child(ren)  alone (check all that apply)

Same room with  adult male  adult female  male child(ren)  female child(ren)  alone (check all that apply)

Philippine General Hospital  Child Protection Unit   526-8418 Page 1

 LIVING ARRANGEMENT AT TIME OF ABUSE Living arrangement at present
 street child  street child
 street family  single parent _______________  street family  single parent ________________
 NGO shelter  immediate family  NGO shelter  immediate family
________________  extended family ________________  extended family
 govt agency  relatives ___________________  govt agency  relatives ___________________
________________  non-relatives ________________  non-relatives
 unknown  unknown

Other Information:

Philippine General Hospital  Child Protection Unit   526-8418 Page 2