ANNEX J: List of Minimum Personal Information for the First Patient

Encounter
A. PhilHealth Identification Number (PIN _______________________________________
B. Name: ________________________________________________________________________________
Last Name First Name Middle Name Extension
C. Date of Birth: _________________________________________________________
Month Day Year

D. Sex: ⃝ Male ⃝ Female

E. Client Type: ⃝ Member ⃝ Dependent

F. Past Medical History: _________________________________________________

G. Family History: _______________________________________________________

Fasting Blood Sugar/Random Blood Sugar

H. Personal and Social History:

I. Smoking YES NO

II. Alcohol YES NO

III. Illicit Drug YES NO

IV. Sexually Active YES NO

I. Vital Signs and Anthropometrics:

I. Blood Pressure: ______________________________________________________

II. Heart Rate: ______________________________________________________

III. Respiratory Rate: ______________________________________________________

IV. Temperature: ______________________________________________________

V. Height: ______________________________________________________

VI. Weight: _______________________________________________________

VII. BMI: _______________________________________________________

Pediatric Client (aged 0-24 months)

I. Middle and Upper Arm Circumference: ________________________________

II. Z-Score (aged 0-60 months): ________________________________