Province of Iloilo

Municipality of Maasin
MUNICIPAL RURAL HEALTH UNIT

INDIVIDUAL TREATMENT RECORD

PERSONAL INFORMATION ADDRESS & CONTACT INFORMATION
Street/ Purok/ Sitio:
Barangay:
Last Name: Municipality: MAASIN
First Name: Mobile Number:
Middle Name: DSWD NHTS Member: [ ] Yes [ ] No
Extension: 4P’s ID Number:
Sex: [ ] Male [ ] Female PHIC Member: [ ] Yes [ ] No
Birthday: / / (mm/dd/yr) [ ] Member [ ] Dependent
Birthplace: OTHER INFORMATION
Civil Status: [ ] Ch [ ] S [ ] M []W DSWD NHTS Member: [ ] Yes [ ] No
Educational Attainment: 4P’s ID Number:
Occupation: PHIC Member: [ ] Yes [ ] No
Religion: [ ] Member [ ] Dependent
Ethnic Group:
Type of Membership
Indigenous: [ ] Yes [ ] No
[ ] NHTS IPP: Employed
Blood Type:
[ ] LGU [ ] OG [ ] Gov’t
Spouse’s Full Name:
[ ] Sponsored [ ] OFW [ ] Private
Mother’s Full Name:
[ ] NGA [ ] Voluntary
Father’s Full Name:
[ ] Private [ ] Self-Employed [ ] Lifetime

IMMUNIZATION STATUS
For Children: For Newborn: For Pregnant Women:

Vaccine Date Time of Birth:

Vaccine Date Date Return
[ ] BCG Birthweight:
[ ] Hepa B w/in 24hrs
[ ] TT1
[ ] Hepa B ≥ 24hrs

[ ] TT2
Vaccine Date Vaccine Date Vaccine Date
[ ] PENTA 1 [ ] OPV 1 [ ] PCV 1 [ ] TT3
[ ] PENTA 2 [ ] OPV 2 [ ] PVC 2
[ ] PENTA 3 [ ] OPV 3 [ ] PVC 3 [ ] TT4
[ ] IPV
[ ] (Measles) [ ] MMR [ ] TT5
[ ] FIC

OB & MENSTRUAL HISTORY LABORATORIES RESULTS

Menarche: y.o. Onset of Sexual Intercourse: y.o. Date
Period Duration: days Interval/ Cycle: days CBC:
No. of Pads/day used during menstruation: pads

G__P__T__P__A__L Urinalysis:
LMP: __/__/20__ AOG of 1st Visit: wks. RBC: RBC:
EDC: __/__/20__ EDC by UTZ: / / 20 WBC: WBC:
PERSONAL & FAMILY MEDICAL HISTORY Bloodtyping:
[ ] Allergy, specify [ ] Thyroid Disease Hepa B Result: [ ] Non-Reactive
[ ] Asthma [ ] Epilepsy/ Seizure Disorder
[ ] Cancer, spfy. Organ [ ] Heart Disease [ ] Reactive
[ ] Diabetes Mellitus [ ] Others: RPR Result [ ] Non-Reactive
[ ] Hypertension [ ] Reactive
Pelvic UTZ Result:
Disability: Smoking: Alcohol Drinker
Handicap: [ ] Yes [ ] No [ ] Yes [ ] No
Impairment:
If Yes, pack/years: If Yes, bottles/day:
Past Surgery: