SORSOGON COMMUNITY COLLEGE LYING-IN CLINIC Form I

Kasanggayahan Compound, Arellano St., Salog, Sorsogon City

FAMILY PLANNING SERVICE RECORD* SIDE A
MEDICAL HISTORY PHYSICAL EXAMINATION

METHOD ACCEPTED:  COC  POP  BTL  VSC

NAME OF SPOUSE: _____________________
NAME OF CLIENT: _____________________
CLIENT NO.: _________
HEENT Blood Pressure:_____mm Hg Weight:_____kg (or lbs.)
ð Epilepsy/Convulsion/Seizure Pulse Rate:_______/min (N.V. = 70 to 80/min)
ð Severe headache/dizziness Height: ________ cm
ð Visual disturbance/blurring of vision CONJUNCTIVA

PLAN MORE CHILDREN :  Yes  No

ð Yellowish conjunctiva ð Pale
ð Enlarged thyroid ð Yellowish
CHEST/HEART NECK
ð Severe chest pain ð Enlarged thyroid

TYPE OF ACCEPTOR:
LAST NAME

LAST NAME
ð Shortness of breath and easy fatigability ð Enlarged lymph nodes
ð Breast/axillary masses BREAST Right Breast Left Breast
ð Nipple discharges (specify if blood or pus) ð Mass
ð Systolic of 140 & above ð Nipple discharge
ð Diastolic of 90 & above ð Skin - orange peel or dimpling
ð Family history of CVA (strokes), hypertension ð Enlarged axillary lymph nodes

______________________ ____ ____/____/_______ ____________________ _______________ __________ ______________ ______

______________________
asthma, rheumatic heart disease THORAX

 New to the Program  Continuing User

ð Abnormal heart sounds/cardiac rate

 IUD
ABDOMEN
ð Mass in the abdomen ð Abnormal breath sounds/respiratory rate

GIVEN NAME
GIVEN NAME

NO. OF LIVING CHILDREN: _______

ð History of gallbladder disease ABDOMEN

 Injectable
ð History of liver disease ð Enlarged liver
GENITAL ð Mass
ð Mass in the uterus ð Tenderness
ð Vaginal discharge EXTREMITIES

 Condom
ð Intermenstrual bleeding ð Edema

____
M.I.
M.I.
ð Postcoital bleeding ð Varicosities
EXTREMITIES PELVIC EXAMINATION

____/____/_______ ____________________
DATE OF BIRTH (mo/day/year)

DATE OF BIRTH (mo/day/year)

ð Severe varicosities

 LAM
ð Swelling or severe pain in the legs not related PERINEUM UTERUS
to injuries ð Scars Position
SKIN ð Warts ð Mid

 SDM

REASON FOR PRACTICING FP: ______________________________________________

ð Yellowish skin ð Reddish ð Anteflexed
HISTORY OF ANY OF THE FOLLOWING ð Laceration ð Retroflexed

PREVIOUSLY USED METHOD: _____________________________

ð Smoking VAGINA Size

 BBT
ð Allergies ð Congested ð Normal

HIGHEST EDUC

HIGHEST EDUC
ð Drug intake (anti-tuberculosis, anti-diabetic, ð Bartholin's cyst ð Small
 Billings/Cervical Mucus/Ovulation Method
anticonvulsant ð Warts ð Large
ð STD ð Skene's Gland ð Mass
ð Multiple partners Discharge Uterine Depth: _____cm.
ð Bleeding tendencies (nose, gums, etc.) ð Rectocoele (for intended IUD users)
ð Anemia ð Cystocoele
_______________

ð Diabetes CERVIX ADNEXA

OCCUPATION

ð Congested ð Mass
OCCUPATION

OBSTETRICAL HISTORY
Number of pregnancies: ð Erosion ð Tenderness
_______ Full Term _______ Premature ð Discharge
_______ Abortions _______ Living Children ð Polyps/cysts
ð Laceration
Date of last delivery ____________________ Consistency
NO. STREET
AVERAGE MONTHLY INCOME : ______

Type of last delivery ____________________ ð Firm

Past menstrual period ____________________ ð Soft
 Sympto-thermal

Last menstrual period ____________________ RISKS FOR VIOLENCE AGAINST WOMEN (VAW)
Duration and character ð History of domestic violence or VAW
BARANGAY

of menstrual bleeding ____________________ ð Unpleasant relationship with partner

HISTORY OF ANY OF THE FOLLOWING ð Partner does not approve of the visit to FP clinic
ð Hydatidiform mole (within the last 12 months) ð Partner disagrees to use FP
ð Ectopic pregnancy Referred to: ð DSWD ð WCPU ð NGOs
 Calenda

STI RISKS ð Others (specify:____________________)

MUNI
  Calendar/Rhythm

_
: ________________
_______________ __________
ð With history of multiple partners

MUNICIPALITY
For Women: ACKNOWLEDGEMENT:
ð Unusual discharge from vagina This is to certify that the Physician/Nurse/Midwife of
ð Itching or sores in or around vagina the clinic has fully explained to me the different methods
ð Pain or burning sensation available in family planning and I freely choose the
ð Treated for STIs in the past ____________________________ method.

PROVINCE
For Men:
ð Pain or burning sensation
ð Open sores anywhere in genital area
ð Pus coming from penis ____________________________ _____________
ð Swollen testicles or penis Client Signature over Printed Name Date
ð Treated for STIs in the past
Reminder: For further evaluation, kindly refer to PHYSICIAN for any checked (√) findings prior to provision of any method.
 SIDE B FAMILY PLANNING SERVICE RECORD
REMARKS
CLIENT NO.: _________

• MEDICAL OBSERVATION
METHOD TO BE
USED/SUPPLIES GIVEN • COMPLAINTS/COMPLICATIONS
• SERVICE RENDERED/PROCEDURES/
INTERVENTIONS DONE (laboratory NEXT
DATE SERVICE NAME OF PROVIDER AND SERVICE
PLAN MORE CHILDREN :  Yes  No

GIVEN examination, treatment, FP referrals, FP SIGNATURE

DATE
counseling, contraceptive dispensing, etc.)
METHOD/ NO. OF • REASONS FOR STOPPING OR CHANGING
BRAND UNITS
METHOD/BRAND
TYPE OF ACCEPTOR:

• OTHER IMPORTANT COMMENTS, IF ANY

 New to the Program  Continuing User
NO. OF LIVING CHILDREN: _______
REASON FOR PRACTICING FP: ______________________________________________
PREVIOUSLY USED METHOD: _____________________________
_____

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