_____________________________________________________
(Name of PCB Provider)
Civil Status: Single Married Annuled Widowed Separated Others, specify ____
PHIC Membership: Type of Membership
Member Sponsored Individually Paying Program (IPP) Employed
Dependent NHTS LGU Organized Group Government
Non-Member NGA Private OFW Private
Occupation: _______________________________________________________________________________
Highest Completed Educational Attainment:
College degree,post graduate High School Elementary Vocational
Past Medical History:
Allergy, specify _____________________ Emphysema Pneumonia
Asthma Epilepsy/Seizure disorder Thyroid disease
Cancer, specify organ_______________ Hepatitis, specify type ____________ Tuberculosis, specify organ _
Cerebrovascular disease Hyperlipidemia If PTB, what category? _____
Coronary artery disease Hypertension, highest BP ________ Urinary tract infection
Diabetes mellitus Peptic ulcer disease Others: _________________
Past Surgical History:
Operation: _____________________________________________ Date: _______________________
Operation: _____________________________________________ Date: _______________________
Family History:
Allergy, specify _____________________ Emphysema Thyroid disease
Asthma Epilepsy/Seizure disorder Tuberculosis, specify organ _
Cancer, specify organ_______________ Hepatitis, specify type ____________ If PTB, what category? _____
Page 1 of 21
Cerebrovascular disease Hyperlipidemia Others: _________________
Coronary artery disease Hypertension
Diabetes mellitus Peptic ulcer disease
Personal/Social History:
Smoking: Yes No Quit No. of pack years? _______________
Alcohol: Yes No Quit No. of bottles/day? _______________
Illicit drugs: Yes No
Page 2 of 21
Immunizations:
For children: BCG OPV1 OPV2 OPV3 DPT1 DPT2
Measles Hepatitis B1 Hepatitis B2 Hepatitis B3 Hepatitis A Varicella (Chic
For young women: HPV MMR For pregnant women: Tetanus toxoid
For elderly and immunocompromised: Pnuemococcal vaccine Flu vaccine
Others: Specify ______________________________________________________________________________
Menstrual History:
Menarche: _________ Onset of sexual intercourse: _________
Last Menstrual Period: ________ Birth control method: _________________
Period Duration: ________ Interval/Cycle: ________ Menopause? Yes No
No. of pads/day during menstruation:________ If yes, at what age?: _________
Pregnancy History:
Gravity(no. of pregnancy): ________ Parity(no. of delivery): _________ Type of Delivery: ___
# of Full term: ________ # of Premature: ______ # of Abortion: _____ # of Living Children: ___
Pregnancy-induced hypertension(Pre-eclampsia)
Access to Family Planning counseling: Yes No
Pertinent Physical Examination Findings:
BP:______________ Height:_________(cm)
HR:______________ Weight:_________(kg)
RR:______________ Waist circumference(cm):________________
Skin: pallor rashes jaundice
__________________________________________________________________________________
__________________________________________________________________________________________
HEENT: anicteric sclerae intact tympanic membrane tonsillopharyngeal congestion
pupils briskly reactive to light alar flaring hypertrophic tonsils
aural discharge nasal discharge palpable mass
__________________________________________________________________________________
__________________________________________________________________________________________
Chest/Lungs: symmetrical chest expansion retractions wheezes
clear breathsounds crackles/rales
_______________________________________________________________________________
_______________________________________________________________________________
Heart: adynamic precordium normal rate regular rhythm heaves/thrills
__________________________________________________________________________________
__________________________________________________________________________________________
Abdomen: flat flabby tenderness
globular muscle guarding palpable mass
__________________________________________________________________________________
__________________________________________________________________________________________
Page 3 of 21
Extremities: gross deformity normal gait full and equal pulses
_______________________________________________________________________________
______________________________________________________________________________________
Page 4 of 21
___
Employed Lifetime
Government
Private
_____________________
No Schooling
_____________
_____________
Page 5 of 21
s: __________________________
______________
_______________
Page 6 of 21
DPT2 DPT3
Varicella (Chicken Pox)
_______________________
urse: _________
________________
____________________
___________________________
_____________________
_____________________
murmurs
____________________
___________________________
____________________
___________________________
Page 7 of 21
equal pulses
_______________________
______________________________
Page 8 of 21
ANNEX A2
PHILIPPINE HEALTH INSURANCE CORPORATION
PCB PROVIDER CLIENTELE PROFILE
OTHER SERVICES
Date Diagnosis Type Remarks
Part II. Please use this part for consultation of illness/well check-up (FP, immunization, etc.). You may use any
equivalent ledger in your facility
Treatment/
Date History of Present Illness Physical Exam Assessment/Impression
Management Plan
ANNEX A4
PHILIPPINE HEALTH INSURANCE CORPORATION
QUARTERLY REPORT FORM
___________________________________________________________
NAME OF PCB PROVIDER
HEALTH FACILITY DATA
SUMMARY OF BENEFITS AVAILMENT (Members and Dependents)
I. Covered Period IV. Obligated Services
From
To TARGET Accomplishment
OBLIGATED SERVICES
(for the quarter) (number)
II. PCB Participation No. Primary preventive services
1. BP measurement
Hypertensive
Nonhypertensive
III. Municipality/City/ Province 2. Periodic clinical breast examination
3. Visual inspection with acetic acid
No. of Members/
V. Members and Dependents Served VI. BENEFITS/SERVICES PROVIDED Dependents VII. Medicines Given No. of Members/
Male: Female: TOTAL Given Referred (Generic Name) Dependents
Members: Primary Preventive Services M D M D I. Asthma M D
Dependents: 1. Consultation
TOTAL 2. Visual inspection with acetic acid
3. Regular BP measurements II. AGE with no or mild dehydration
VIII. Top 10 Common Number of 4. Breastfeeding program education
Illnesses (Morbidity) Cases 5. Periodic clinical breast examinations
6. Counselling for lifestyle modification
7. Counselling for smoking cessation
8. Body measurements III. URTI/Pneumonia (minimal & low risk)
9. Digital rectal examination
Diagnostics Examinations
1. Complete blood count (CBC)
2. Urinalysis IV. UTI
3. Fecalysis
4. Sputum miroscopy
5. Fasting blood sugar (FBS) V. Nebulisation services
6. Lipid profile
IX. CERTIFICATION 7. Chest x-ray
This is to certify that the foregoing information are true and correct and all of the beneficiaries served are assigned and enlisted under our facility.
____________________________________________________ ________________________________________________
Printed name and signature of Nurse/ Midwife Printed name and signature of Physician
H INSURANCE CORPORATION
RLY REPORT FORM
__________________________________
OF PCB PROVIDER
TH FACILITY DATA
VAILMENT (Members and Dependents)
Accomplishment
(number)
No. of Members/
Dependents
D
IV. UTI
V. Nebulisation services
beneficiaries served are assigned and enlisted under our facility.
________________________________________________
ANNEX A5
Philippine Health Insurance Corporation
PCB FORM 1A
QUATERLY SUMMARY OF PCB SERVICES PROVIDED
_________________________________________________________
NAME OF HEALTH CARE PROVIDER
Regular BP measurement
Body measurements
Sputum Microscopy
Digital rectal exam
Membership
Consultation
modification
examination
Lipid profile
Chest x-ray
education
Urinalysis
cessation
Fecalysis
PHILHEALTH
Date NAME SEX AGE DIAGNOSIS
acid
CBC
FBS
NUMBER
1 M
D M
F
2 M
D M
F
3 M
D M
F
4 M
D M
F
5 M
D M
F
6 M
D M
F
7 M
D M
F
8 M
D M
F
9 M
D M
F
10 M
D M
F
11 M
D M
F
12 M
D M
F
13 M
D M
F
14 M
D M
F
15 M
D M
F
TOTAL
This is to certify that the foregoing information are true and correct and all of the beneficiaries served are assigned and enlisted under our facility .