Facility Code

Family Serial Number

Integrated Clinic Information System (iCLINICSYS)

PATIENT ENROLMENT RECORD

Instructions: For new patient only. Please print legibly and mark appropriate boxes with “X”.
Para sa mga bagong pasyente lamang. Mangyaring isulat nang malinaw at markahan ang naangkop na kahon ng “X”.
I. PATIENT INFORMATION (IMPORMASYON NG PASYENTE)
Last Name Suffix
(Apelyido) (e.g. Jr., Sr., II, III)
First Name Please write Maiden Name (for married women)
(Pangalan) Pangalan sa pagkadalaga (para sa mga babaeng may-asawa)
Middle Name
(Gitnang Pangalan)
Mother’s Name
Sex (Kasarian) Female (Babae) Male (Lalaki)
(Pangalan ng Ina)
Birth Date
(Kapanganakan)
(mm/dd/yyyy) / /
Birthplace
(Lugar ng Kapanganakan)
Residential Address
Blood Type
(Tirahan)
Single Widow/er
(Walang Asawa) (Balo)
Married Separated
Civil Status (May Asawa) (Hiwalay)
(Katayuang Sibil)
Co-Habitation Contact Number
Annulled
(Paninirahang
(Anulado) DSWD NHTS? Yes No
magkasama)
Spouse’s Name Facility Household
(Asawa) No.
No Formal Education 4Ps Member? Yes No
Elementary
(Walang Pormal na
Educational (Elementarya) Household No.
Edukasyon)
Attainment
High School Vocational
(Pang-edukasyong PhilHealth Member? Yes No
(Hayskul) (Bokasyunal)
katayuan)
College
Post Graduate Status Type: Member Dependent
(Kolehiyo)
Student Unknown
Employment PhilHealth No.
(Estudyante) (Hindi malaman)
Status Employed Retired
(Katayuan sa FE – Private:
(May trabaho) (Retirado)
Pagtatrabaho)
None/Unemployed (Walang Trabaho) If Member, please FE – Government:

Father (Ama) Mother (Ina) indicate category IE:

Family Member Son Daughter
(Posisyon sa Others:
(Anak na lalaki) (Anak na babae)
Pamilya) Primary Care Benefit
Others (Iba) ____________________ Yes No
(PCB) Member?
II. PATIENT’S CONSENT (PAHINTULOT NG PASYENTE)

IN ENGLISH SA FILIPINO

I have read and understood the Patient’s Information
after I have been made aware of its contents. During an
informational conversation I was informed in a very
comprehensible way about the essence and importance of the
Integrated Clinic Information System (iClinicSys) by the
CHU/RHU representative. All my questions during the
conversation were answered sufficiently and I had been given
enough time to decide on this.
Aking nabasa at naintindihan ang Impormasyon ng
Pasyente matapos ako’y bigyang-kaalaman ng mga nilalaman
nito. Sa isang pag-uusap kasama ang kinatawan ng CHU/RHU,
ako ay binigyang-paunawa nang mahusay tungkol sa kakanyahan
at kahalagahan ng Integrated Clinic Information System
(iClinicSys). Lahat ng aking mga katanungan sa panahon ng pag-
uusap ay nasagot ng sapat at ako ay binigyan ng sapat na oras
upang magpasya nito.

Furthermore, I permit the CHU/RHU to encode the Higit pa rito, pinapayagan ko ang CHU/RHU upang i-encode
information concerning my person and the collected data ang mga impormasyon patungkol sa akin at ang mga nakolektang
regarding disease symptoms and consultations for said impormasyon tungkol sa mga sintomas ng aking sakit at
information system. konsultasyong kaugnay dito para sa nasabing information system.

I wish to be informed about the medical results
concerning me personally or my direct descendants. Also, I
can cancel my consent at the CHU/RHU any time without
giving reasons and without concerning any disadvantage for
my medical treatment.
Nais kong malaman at maipaalam sa aking direktang
kapamilya ang aking mga medikal na resulta. Gayundin, maari
kong kanselahin ang aking pahintulot sa CHU/RHU anumang oras
na walang ibinibigay na dahilan at walang kinalaman sa anumang
kawalan para sa aking medikal na pagpapagamot.

____________________________________ ____________________________________
SIGNATURE OF PATIENT / DATE NAME OF CHU/RHU REPRESENTATIVE
PIRMA NG PASYENTE / PETSA KINATAWAN NG CHU / RHU
Clinic Information System | FORM 1
 Facility Code
Family Serial Number

Integrated Clinic Information System (iCLINICSYS)

INDIVIDUAL TREATMENT RECORD

Instructions: For old, returning and/or referred patient. Please print legibly and mark appropriate boxes with “X”.
Para sa mga pasyente. Mangyaring isulat nang malinaw at markahan ang naangkop na kahon ng “X”.
I. PATIENT INFORMATION (IMPORMASYON NG PASYENTE)
Last Name Suffix Age
(Apelyido) (e.g. Jr., Sr., II, III) (Edad)
First Name
(Pangalan) Residential
Address
Middle Name (Tirahan)
(Gitnang Pangalan)
II. FOR CHU / RHU PERSONNEL ONLY (PARA SA KINATAWAN NG CHU / RHU LAMANG)
Walk-in For REFERRAL Transaction only.
Mode of REFERRED
Visited
Transaction FROM
REFERRED
Referral
TO
Date of
/ / (mm/dd/yyyy)
Consultation
Consultation Time AM / PM Reason(s)
for Referral
Blood Pressure Temperature

Height (cm) Weight (kg)

Name of Attending
Referred by
Provider
New Consultation/Case
Nature of Visit New Admission
Follow-up visit
General Family Planning
Prenatal Postpartum
Chief
Dental Care Tuberculosis Complaints:
Type of
Child
Consultation / Child Care
Immunization
Purpose of visit
Child Nutrition Sick Children
Injury Firecracker Injury
Adult Immunization

Diagnosis:

Name of Health Care Provider:

Medication /
Treatment:

Performed Laboratory Test:

Laboratory
Findings /
Impression:

Clinic Information System | FORM 2 | Page 1

Family Planning Child Immunization
Type of Client Birth Weight

Method Immunization Date

Hepa B w/in 24
If Drop-Out, state reason:
hrs
Schedule of Next Visit: Hepa B ≥ 24 hrs

Prenatal PENTA 1
Gravidity LMP PENTA 2
Parity EDC PENTA 3
Term AOG OPV 1
Preterm TT OPV 2
Livebirth Iron OPV 3
Abortion Others MCV 1 (AMV)
Syphilis
Negative Positive MCV 2 (MMR)
Result
Penicillin No Yes ROTA 1

Schedule of Next Visit ROTA 2

Fundic Height (cm) PCV 1
Fetal Heart Tone PCV 2

Prenatal Visits PCV 3

Hepa B2

Hepa B3

Hepa A

Pneumonia

Menstrual History Influenza

Others:
Onset of
Menarche sexual
intercourse

Adult Immunization
Birth
Period/
Control Immunization Date
Duration
Method
Pneumococcal
Flu
Interval/ Menopause? Others:
Cycle (Yes/No)

Postpartum
Prenatal Outcome Child information
Last Name Sex (M / F)
First Name Birth length
Middle Name Birth weight

Prenatal Delivered Delivery Date

Place Delivered Delivery Time

Date Initiated
Mode of Delivery
Breastfeeding
Time Initiated
Attendant at Birth
Breastfeeding
Date of postpartum visit within 24hrs after delivery / / Danger Signs (Mother)
Date of postpartum visit within 1 week after delivery / / Danger Signs (Baby)
No. of Iron
Date Vitamin A Given / / Date Iron Given / /
Given
Clinic Information System | FORM 2 | Page 2