Form 2: HEALTH SCREENING AND ASSESSMENT FORM

Name of Patient: _____________________________________________________ Age/Sex: ___________ Barangay: ____________________ Date: _____________

PAST MEDICAL HISTORY Others Heart

 Allergy: __________________________  COVID-19 Vaccine (Primary Series)  Essentially Normal
 Asthma  COVID-19 Vaccine (Booster)  Displaced apex beat
 Cancer: __________________________  Heaves/thrills
 Cerebrovascular Disease FAMILY PLANNING HISTORY ( NA)  Irregular rhythm
 Coronary Artery Disease  Muffled heart sounds
 Diabetes Mellitus With access to family planning counselling?  Murmurs
 Emphysema  Yes  No  Pericardial bulge
 Epilepsy/Seizure Disorder  Others:
 Hepatitis MENSTRUAL HISTORY ( NA) _________________________________
 Hyperlipidemia _________________________________
 Hypertension (Highest BP: _____ / ____ ) Menarche: _______ y/o _________________________________
 Peptic Ulcer Disease Onset of Sexual Intercourse: _______ y/o
 Pneumonia Menopause? ( ) Yes ( ) No Abdomen
 Thyroid Disease Age of Menopause: ________ y/o  Essentially normal
 Pulmonary Tuberculosis LMP: _____________________________________  Abdominal rigidity
(Category: _______________________) Period duration: _________ days  Abdominal tenderness
 Extrapulmonary Tuberculosis No. of pads / day: ________ pads  Hyperactive bowel sounds
(Site: ___________________________) Interval Cycle: ___________ days  Palpable mass(es)
 Urinary Tract Infection Current Birth Control Method:  Tympanitic/dull abdomen
 Mental Illness  NONE  Uterine contraction
 Others: __________________________  _________________________________  Others:
 NONE _________________________________
PREGNANCY HISTORY ( NA) _________________________________
PAST SURGICAL HISTORY (Operation, Year) _________________________________
 _________________________________ Gravidity: ______ Parity: ______
Term: ___ Preterm: ___ Abortion: ___ Living: ___ Genitourinary:
 _________________________________
Type of Delivery: ( ) NSD ( ) CS ( ) Both  Essentially normal
 _________________________________
Prenancy-induced hypertension ( ) Yes ( ) No  Blood stained in exam finger
FAMILY HISTORY  Cervical dilatation
PERTINENT PHYSICAL EXAMINATION FINDINGS  Presence of abnormal discharge
 Allergy
 Asthma  Others:
BP: _______ / ________ mmHg _________________________________
 Cancer
HR: _______ bpm _________________________________
 Cerebrovascular Disease
RR: _______ cpm _________________________________
 Coronary Artery Disease
Temp: _____ C
 Diabetes Mellitus
 Emphysema Digital Rectal Exam
Height/Length: _________ cm  Essentially normal
 Epilepsy/Seizure Disorder Weight: ________ Kg
 Hepatitis  Enlarged prostate
 Hyperlipidemia  Mass
For 0-24 months
 Hypertension  Haemorrhoids
Head Circumference: ___________ cm
 Peptic Ulcer Disease  Pus
Triceps Skinfold Thickness: __________ cm
 Pneumonia  Not applicable
Waist Circumference: __________ cm
 Thyroid Disease  Others:
Hip Circumference: __________ cm
 Pulmonary Tuberculosis _________________________________
Limb (Thigh) Circumference: __________ cm
 Extrapulmonary Tuberculosis _________________________________
MUAC: _________ cm
 Urinary Tract Infection _________________________________
 Mental Illness Blood type: ________
Skin / Extremities
 Others
General Survey:  Essentially normal
 NONE
 Awake and Alert  Clubbing
PERSONAL / SOCIAL HISTORY  Altered Sensorium: _________________  Cold clammy
 Smoking ( ) Yes ( ) No  Cyanosis/mottled skin
 Alcoholic ( ) Yes ( ) No PERTINENT FINDINGS PER SYSTEM  Edema/swelling
 Illicit Drugs ( ) Yes ( ) No  Decreased mobility
 Sexually Active ( ) Yes ( ) No HEENT  Pale nailbeds
 Essentially Normal  Poor skin turgor
IMMUNIZATION HISTORY  Abnormal Pupillary Reaction  Rashes/petechiae
 Cervical Lymphadenopathy  Weak pulses
For Children ( NA)  Dry mucous membrane  Others:
 BCG  Measles  Icteric sclerae _________________________________
 OPV 1  Hepatitis B 1  Pale conjunctivae _________________________________
 OPV 2  Hepatitis B 2  Sunken eyeballs _________________________________
 OPV3  Hepatitis B 3  Sunken fontanels
Neurological Examination
 DPT 1  Hepatitis A  Others:
_________________________________  Essentially normal
 DPT 2  Varicella
_________________________________  Abnormal gait
 DPT 3  NONE
_________________________________  Abnormal position sense
For Adults ( NA)  Abnormal sensation
 HPV Chest / Breast / Lungs  Abnormal reflex(es)
 MMR  Essentially Normal  Poor/altered memory
 None  Asymmetrical chest expansion  Poor muscle tone/strength
 Decreased breath sounds  Poor coordination
For Pregnant Women ( NA)  Wheezes  Others:
 Tetanus Toxoid  Lumps over breast(s) _________________________________
 Crackles/rales _________________________________
 None
 Retractions _________________________________
For Elderly and Immunocompromised ( NA)  Others:
 Pneumococcal Vaccine _________________________________
 Flu Vaccine _________________________________
 None _________________________________
NCD HIGH RISK ASSESSMENT (For 25 years old and above)

High Fat / High Salt Food Intake

Eats processed/fast foods (e.g. instant noodles, hamburgers, fries, fried chicken skin etc.) and ihaw-ihaw (e.g. isaw, adidas, etc.) weekly
 Yes
 No

Dietary Fiber Intake

3 servings of vegetables daily
 Yes
 No
2-3 servings 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

Was patient diagnosed as having diabetes?
 Yes
 No
 Do not know
If yes
 With medication
 Without medication
Does patient have the following symptoms?
Polyphagia
 Yes
 No
Polydipsia
 Yes
 No
Polyuria
 Yes
 No

Raised Blood Glucose

 Yes FBS/RBS: __________ mg/dL
 No Date Taken: _____________

Raised Blood Lipids

 Yes Total Cholesterol: ________
 No Date Taken: _____________

Presence of Urine Ketones

 Yes Urine Ketone: ___________
 No Date Taken: _____________

Presence of Urine Protein

 Yes Urine Protein: ___________
 No Date Taken: _____________

Questionnaire to Determine Probable Angina, Heart Attack, 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
2. Do you get the pain in the center of the chest or left arm? ( ) Yes ( ) No
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. Do the pain go away if you stand still or if or take a tablet under the tongue? ( ) Yes ( ) No
6. Does the pain go 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 6 or 7 is YES, patient have angina or heart attack and needs to see a 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 ( ) Yes ( ) No
on one side of the body or numbness on one side of the body?

If the answer to Question 8 is YES, the patient may had a TIA or stroke and needs to see a doctor.

RISK LEVEL
 <10%
 10% to 20%
 20% to 30%
 30% to 40%
 >40%
BHW/Family Navigator Midwife Nurse Physician