Republic of the Philippines
Department of Education
Region VI – Western Visayas
DIVISION OF CAPIZ
Name:_________________________________________________________________________Age:__________Sex:_________
Prefix Last Name First Name Middle Name Suffix
Address:____________________________ ___________________________ ___________________ ______________
No. Street Barangay City/Municipality Province
Birth date: Birth place: Blood type: Religion: Nationality:___________
Indigenous Group: Yes No
Civil Status: Co-habitation Educ.Attainment: Elem H.S Employment Status: Self-Employed
Single Married Widow College Post Grad Vocational Retired Employed Unemployed
Separated Annulled No form of Educ. Not applicable Nature of work: _________________
Smoker? Yes No Passive Smoker How long?________ Willing to Stop? Yes No Stopped: > a year < a
year
Alcohol Intake: Never Consumed Yes, Drinks Alcohol Excessive intake in the past month: Yes No
Physical Activity: Does at least 21/2 hours a week of moderate-intensity physical activity Yes No
Family History: Does patient have 1st degree relative with:
Hypertension Asthma Stroke Cancer Heart attack Kidney stone Diabtetes
Mother’s first Name Middle Name Last Name Birthdate
- CONSENT FOR PARTICIPATION TO PHIE
1. I hereby give my full consent and permission to this facility to gather send and transmit pertinent data or information (with appropriate safety measures to
protect the privacy and security of my well being , health information and other rights under laws governing data privacy, security and related issuances? until
it is revoked by myself or my duly authorized representative.
2. I am made aware that I can cancel my consent at any time without giving reasons and without concerning any disadvantage for my medical treatment
services.
I Certify that I have been made to understand my rights in language and manner understandable to me by a representative of the facility/health care provider
and that the health data or information is true and complete to the best of my knowledge.
Signed this ______ day of___________________________________,202___. Time: __________________
___________________________________________________ ____________________________________________________________
Signature Over Printed Name of Patient/Representative Signature Over Printed Name of Health Provider
Mobile/Landline No.: ________________________________
Pertinent Health Information, Intervention, and Procedures
O:
WT:______________kg HT___________cm S:
RR:_______________
Temp:_____________ Rechecked:___________
Heart/Pulse Rate:___ A:
Regular rhythm: Yes No
Normal rate: Yes No
BP: _______/_________ (Rechecked): _____/____ P:
BMI:____________ BMI Category:__________
Risk prediction:______________________
Waist circumference__________________cm
Central adiposity: Yes No
Obesity: Yes No
Assessed by: __________________________
Date: ________________ Time: __________
_________________________________________________
_______________________________
Joy Arnold Talabucon- Lejos, MD
Medical Officer III
Lic. No. 0099321
Name: ______________________________________________________________ Age: _________ Civil Status:
____________
Name: _____________________________________________________________________ Age: _____
Last Name First Name Middle Name Suffix
Civil Status: ______
FOLLOW – UP CONSULTATION
O:
WT:______________kg HT___________cm S:
RR:_______________
Temp:_____________ Rechecked:___________
Heart/Pulse Rate:_____ A:
Regular rhythm: Yes No
Normal rate: Yes No
BP: _______/_________ (Rechecked): _____/____ P:
BMI:____________ BMI Category:__________
Risk prediction:______________________
Waist circumference__________________cm
Central adiposity: Yes No
Obesity: Yes No
Assessed by: __________________________
Date: ________________ Time: __________
_________________________________________________
_______________________________
Joy Arnold Talabucon- Lejos, MD
Medical Officer III
Lic. No. 0099321
Name: ______________________________________________________________ Age: _________ Civil Status: ____________
Last Name First Name Middle Name Suffix
FOLLOW – UP CONSULTATION
O:
WT:______________kg HT___________cm S:
RR:_______________
Temp:_____________ Rechecked:___________
Heart/Pulse Rate:______ A:
Regular rhythm: Yes No
Normal rate: Yes No
BP: _______/_________ (Rechecked): _____/____ P:
BMI:____________ BMI Category:__________
Risk prediction:______________________
Waist circumference__________________cm
Central adiposity: Yes No
Obesity: Yes No
Assessed by: __________________________
Date: ________________ Time: ________
_____________________
_____________________________
Joy Arnold Talabucon- Lejos, MD
Medical Officer III
Lic. No. 0099321
