REPUBLIC OF THE PHILIPPINES

CITY/MUNICIPALITY OF ________________
CITY/RURAL HEALTH OFFICE
INTEGRATED BARANGAY HEALTH MONITORING REPORT AS OF _____
.

PATIENT DATE OF DATE OF WEIGHT HEIGHT

DATE
NAME ARRIVAL ARRIVAL AGE SEX ZONE
CODE REPORTED
(PHILIPPINES) (TOWN) (kg) (cm)

(a-1) (a-2) (b) (c) (d) (e) (f) (g) (h) (i)

Hinabangan-0 ex. DELA CRUZ, JUAN T. 3/16/2020 3/15/2020 3/15/2020 34 yrs MALE 60 155

Hinabangan-1
Hinabangan-2

Hinabangan-3
DESCRIPTIONS:

LGU name or
first three (3)
Patient full name; for LGU Confidential use Date of report
letter of LGU Date of Arrival in the Date of Arrival in Age in
name and only and remove this column upon final received from Philippines the Municipality Days/Months/Y Sex Weight in Height in Barangay Zone
submission of report to LMP BHW kilograms centimeters / Subdivision
numerical (mm/dd/yyyy) (mm/dd/yyyy) ear
order (DELA CRUZ, JUAN T.) (mm/dd/yyyy)
(ex. DAR-1)
ES
_______
E
REPORT AS OF ______________

TRAVEL SIGNS AND DATE OF THE DATE OF THE END

BARANGAY NATIONALITY START OF SIGNS OF SIGNS &
HISTORY/EXPOSURE SYMPTOMS & SYMPTOMS SYMPTOMS

(j) (k) (l) (m) (n) (o)

TAIWAN-MANILA- COUGH AND SORE

Rawis FILIPINO 3/15/2020
TACLOBAN-PALO THROAT
 Signs and Symtoms DATE OF THE START DATE OF THE END OF
(Multiple answers) ex. OF SIGNS &
SIGNS & SYMPTOMS
Fever (in oC), Cough, SYMPTOMS
Barangay Nationality Complete Travel History (mm/dd/yyyy) ; N/A if
Sore Throat, Difficulty (mm/dd/yyyy) ; N/A if
no signs and
of Breathing, Muscle no signs and
symptoms; Blank if
Pains, Diarrhea, Lack symptoms; Blank if still on-going
of Smell and Taste still on-going
 PRE-EXISTING RISKY CONDITIONS (DIABETES,
OTHER KNOWN DISEASES AND
INTERVENTION HYPERTENSION, CANCER, KIDNEY PROBLEM,
ILLNESSES
ASTHMA, TB, COPD AND EVEN PREGNANCY)

(p) (q) (r)

ADVISED WEARING OF MASK AND OTHER PRECAUTIONARY

MEASURES; INCREASE FLUID INTAKE; CONTINUE ANTI-ASTHMA ASTHMA SCHISTOSOMIASIS, GOUT
MAINTENANCE AND ADVISED STRICT HOME ISOLATION
 PRE-EXISTING RISKY CONDITIONS (DIABETES, HYPERTENSION,
Interventions from bhw, midwife, nurse in the Barangay Health CANCER, KIDNEY PROBLEM, ASTHMA, TB, COPD AND EVEN OTHER KNOWN DISEASES AND ILLNESSES apart
Center to MHO in RHU up to the hospital of referral from the pre-existing conditions
PREGNANCY)
 STATUS
OTHER REMARK/S

(s) (t)

COMPLETED QUARANTINE STILL W/ MILD OCCASSIONAL COUGH

 Indicate Current Status of
patient
(MONITORED, RECOVERED, Other pertinent information related to patients
COMPLETED QUARANTINE, condition and his/her case management
ADMITTED, DISCHARGED,
ETC.)