Republic of the Philippines

Province of Isabela
CITY OF ILAGAN

CITY HEALTH OFFICE – II

Marana 1st, City of Ilagan, Isabela
Email: cho2ilagan@gmail.com
ISO 9001:2015

ADOLESCENT HEALTH AND DEVELOPMENT PROGRAM

INDIVIDUAL TREATMENT RECORD

NAME: ________________________________ AGE: ________ SEX: ______ BIRTHDAY:__________

ADDRESS: _____________________________
CIVIL STATUS: _____________ EDUCATIONAL ATTAINMENT: _______________
IN SCHOOL: ____ OUT OF SCHOOL: ______ PHIC NO.: _______________________
CONTACT NUMBER: ________________________

DATE  Complaints/ SERVICES

complication  Counseling
 Medical  Immunization
Observation  Smoke Cessation
 PE Findings  Provision of FP Commodities
 HEADDS  Iron Supplementation Name of Provider NEXT Follow-
Assessment  Provision of Mental Health and Signature up Schedule
 Others drugs
important  Ante Natal, Post-partum check
comments if up
any  Newborn Screening
 Republic of the Philippines
Province of Isabela
CITY OF ILAGAN

CITY HEALTH OFFICE – II

Marana 1st, City of Ilagan, Isabela
Email: cho2ilagan@gmail.com
ISO 9001:2015