ANNEX A1

PHILIPPINE HEALTH INSURANCE CORPORATION

_____________________________________________________
(Name of PCB Provider)

INDIVIDUAL HEALTH PROFILE

Print legibly. Mark appropriate boxes c with " ü " PIN:

Patient Name:
(Last Name) (First Name) (Middle Name) (Extension: Sr., Jr., etc.)
Note: If this is a follow-up consult or 2nd visit, please indicate if there are any changes in the Basic Demographic Data.
Updating of this Individual Health Profile must be done before the fiscal year ends, to include review of consultation
records (Annex A.3) Indicate the date when the new data has been entered. Please use additional page when necessary.
Address:
Age: 0 – 1 year 2 - 5 years 6 - 15 years 16 - 24 years 25 – 59 years 60 years and above
Birthdate:
(mm/dd/yyyy)
/ / Sex: Male
Female
Religion:

Civil Status: Single Married Annuled Widowed Separated Others, specify ______________
PHIC Membership: Type of Membership
Member Sponsored Individually Paying Program (IPP) Employed Lifetime
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 No Schooling
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? _____________
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 1 of 6
Immunizations:
For children: BCG OPV1 OPV2 OPV3 DPT1 DPT2 DPT3
Measles Hepatitis B1 Hepatitis B2 Hepatitis B3 Hepatitis A Varicella (Chicken Pox)

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 good skin turgor
_________________________________________________________________________________________
_____________________________________________________________________________________________________
HEENT: anicteric sclerae intact tympanic membrane tonsillopharyngeal congestion exudates
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 murmurs
_____________________________________________________________________________________
__________________________________________________________________________________________________
Abdomen: flat flabby tenderness
globular muscle guarding palpable mass
_____________________________________________________________________________________
__________________________________________________________________________________________________
Extremities: gross deformity normal gait full and equal pulses
_____________________________________________________________________________________
_________________________________________________________________________________________________

Page 2 of 6
ANNEX A3
PHILIPPINE HEALTH INSURANCE CORPORATION
PCB PATIENT LEDGER

NAME OF HEALTH CARE FACILITY

Part I
Name: ______________________________________________ Age: _____________ Sex: ___________
Address: ____________________________________________ PIN: _________________________
`
( ) PHIC Sponsored IPP Employed ( ) Lifetime
( ) Member ( ) NHTS ( ) LGU ( ) OG ( ) Government
( ) Dependent ( ) NGA ( ) Private ( ) OFW ( ) Private
( ) NON PHIC ( ) Voluntary/self employed
OBLIGATED SERVICES
Date Performed
Primary preventive services Frequency
1st Qtr 2nd Qtr 3rd Qtr 4th Qtr
1. BP measurements
Hypertensive Once a month
Nonhypertensive Once a year
2. Periodic clinical breast Once a year
examination
3. Visual inspection with acetic Once a year
acid

PART I. DIAGNOSTIC EXAMINATION SERVICES

Date Diagnosis Type Given Referred Remarks

OTHER PCB1 SERVICES

Date Diagnosis Type Remarks

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