INDIVIDUAL HOUSEHOLD MEMBER HEALTH PROFILE
Name of HRH: Cadre:
Contact No.
Initial Profiling Date:
Updating Date:
Patient's CODE
PhilHealth Membership: Direct Member Indigenous People: Yes
Indirect Dependent No
A. PERSONAL PROFILE
Patient's
Name: Last Name First Name Middle Name Extension
Rel a ti ons hi p to the Hea d of the Fa mi l y: Head of the Family If Head of the Family,
please indicate No. of Dependents :
Spouse/Partner Child
Parent Uncle/Aunt
Grand parent Others, please specify:
Address: Ci vi l Sta tus :
Birthday: Age: OSCA ID No. (If Senior Citizen ) Sex: Male
Religion: Occupation: Female
Highest Completed Educational Attainment:
No Schooling Vocational
Elementary College
High School Post-graduate
Blood Type: _______ History of Blood Donation: Yes
No
B. PAST MEDICAL HISTORY
C. PRESENT MEDICAL CONDITION
Undergoing Dialysis Treatment
Yes , where?
Medications (if any):
D. PAST SURGICAL HISTORY
Surgery: Date:
Surgery: Date:
E. DISABILITY PWD ID No.
Mobi l i ty/Phys i ca l Impa i rment Vi s i on Di s a bi l i ty Cogni ti ve or Lea rni ng Di s a bi l i ti es
Spi na l Cord Injury Di s a bi l i ty Hea ri ng Di s a bi l i ty Invi s i bl e Di s a bi l i tes
Hea d Injuri es - Bra i n Di s a bi l i ty Ps ychol ogi ca l Di s order, Need for a s s i s ti ve devi ce?
Please Specify : ___________ Please specify:________________________________
F. FAMILY HISTORY
Hypertens i on Ki dney Di s ea s e
Stroke Ca ncer
Hea rt Atta ck Menta l Il l nes s
Di a betes Tubercul os i s
As thma Others :
G. PERSONAL SOCIAL HISTORY
G.1. SMOKING
Never Smoked Current Smoker
Stopped more tha n a yea r No. of Pa cks /da y:
Stopped l es s tha n a yea r Pa s s i ve Smoker
Yea r Sta rted:
Yea r Stopped:
G.2. ALCOHOL G.3. ILLICIT DRUGS
Never Cons umed Yes
Yes No. of Bottl es per da y: No
G.4. HIGH SALT/HIGH FAT FOOD INTAKE G.5. DIETARY FIBER INTAKE G.6. PHYSICAL ACTIVITY
Yes 3 s ervi ngs of vegeta bl es da i l y 2 1/2 hours a week of modera te-
No 2-3 s ervi ngs of frui ts da i l y i ntens i ty phys i ca l a cti vi ty
H. IMMUNIZATION RECORD
For Children 0-12 months: BCG Penta 1 OPV 1 PCV-13 1 MMR 1
Hep B Penta 2 OPV 2 PCV-13 2 MMR 2
Penta 3 OPV 3 PCV-13 3
IPV Others, please specify:
For Gradeschooler:
Grade 1: MR Td
Grade 7: MR Td
Grade 4 (Female 9-10 years old): HPV 1
HPV 2
For Pregnant Women: Td 1 Td2 Td3 Td4 Td5
For Elderly and Immunocompromized: Flu Vaccine, date given: ____________________
PPV-23
Others, please specify: _____________________
I. DEWORMING STATUS
For 1-4 Years old For 5-19 years old
Yes Yes
No No
J. MENSTRUAL HISTORY
Menarche:
Onset of sexual intercourse:
Menopause? Age:
Regular
Irregular. If irregular, menstruation happens ONCE every:
Period Duration:
No. of pads per day during menstruation:
l Birth control method: Source:
K. PREGNANCY HISTORY
Gravidity Preterm
Parity Abortion
Full Term No. of living children
Pregnancy-induced hypertension? Y/N
Gestational Diabetes Mellitus? Y/N
L. PERTINENT PHYSICAL EXAMINATION
l BP l HR
l Temperature l RR
l Height in cm. l Weight in kg.
l BMI l Central Adiposity?
l Waist circumference in cm. l Obese?
M. AWARENESS ON DOH PROGRAMS FOR DIFFERENT DISEASES
Bl i ndnes s Mea s l es DM Others :
Dengue Tubercul os i s Ca ncer
HIV/STI Menta l Il l nes s Chroni c Ki dney Di s ea s e
Lepros y Hypertens i on Food a nd Wa ter Borne Di s ea s es ( Cho lera, Typho id, Hepa A , Ro tavirus, A cute B lo o dy Diarrhea )
N. ACCESS TO SOURCES OF HEALTH INFORMATION
Television Radio Newspaper Social Media Others, please specify:
_____________________
O. ACCESS TO NEAREST HEALTH FACILITY
Barangay Health Station Rural Health Unit Hospital Others, please specify: ___________
Distance: ________ meters kilometers Estimated Time of travel:__________
Mode of Travel : Walking Vehicle (type) __________ Others, please specify: ___________
P. FOR DIAGNOSTIC PROCEDURES/REFERRAL/FOLLOW-UP
P.1. Diagnostic Procedures: CBC/Hgb Blood Glucose Others, please specify:
Urinalysis Chest X-ray _____________________
Fecalysis Sputum Exam
P.2. Reason for Referral/Follow-up:
Individual Health Profile Form Rev.0
