The Republic of the Philippines KonSulTa No.

: _________________
Province of Misamis Oriental PHIC No.: ____________________  NEW CONSULTATION
MUNICIPAL HEALTH OFFICE NHTS _____ Private _____
4P’s _______ Senior _____  FOLLOW-UP
Member _____ None _____
Dependent _____ PWD _____

Name: __________________________________________ Age: ________ DOB: ______________ Sex: ________

PAST MEDICAL HISTORY:

AllergyEpilepsy/Seizure DisorderThyroid Disease
AsthmaHepatitis Pulmonary Tuberculosis
CancerHyperlipidemia Extrapulmonary Tuberculosis
Coronary Artery Disease Hypertension Urinary Tract Infection
Diabetes Mellitus Peptic Ulcer Mental Illness
Emphysema Pneumonia Others None
Specify Allergy: ______________________________Specify Pulmonary Tuberculosis category: ___________________
Specify Organ w/ Cancer: ______________________Specify Extrapulmonary Tuberculosis category: _______________
Specify hepatitis type: _________________________Others, please specify: ___________________________________
Highest blood pressure: ______________________________________________________________________________

PAST SURGICAL HISTORY

Operation: ______ __________________________________Date: _______________________________

PERSONAL/SOCIAL HISTORY
Smoking: Yes No QuitNo. of packs/year: _________Illicit Drugs: YesNo
Alcohol: Yes No QuitNo. of bottles/day: _________Sexually Active : YesNo

IMMUNIZATIONS
For Children: For Adult: For Elderly and Immunocompromised:
BCG Measles HPV Pnuemococcal Vaccine
OPV1 Hepatitis B1 MMR Flu Vaccine
OPV2 Hepatitis B2 None None
OPV3 Hepatitis B3 For Pregnant Women:
DPT1 Hepatitis A Tetanus Toxoid
DPT2 Varicella (Chicken Pox) None
DPT3 None Others, Please Specify: _______________________________________________

FAMILY PLANNING
With access to family planning counseling? YesNo
MENSTRUAL HISTORY:Applicable Not ApplicablePREGNANCY HISTORY
Menarche: ______yrs.oldOnset of sexual intercourse: ______Gravidity (no. of pregnancy): ______ Parity (no. of delivery): _______
Last Menstrual period: ______Birth control method:____________Type of delivery: NormalCSD

Period Duration: _____days Interval cycle:______ daysNo. of full term: _______No. of premature: _________
No. Of pads/day during menIstruation: ____No. of abortion: _______No. of living children: ________
Menopause?: Yes No If yes, what age: ______yrs oldPregnancy-induced hypertension (Pre-eclampsia): Yes/No
PERTINENT PHYSICAL EXAMINATION FINDINGS
BP: ______Height: ________Pediatric Client aged 0-24 months
HR: ______Weight: ________Length: ____cm Head Circumference:____cm Skinfold Thickness: _____cm
RR: ______Temperature: ________Waist: ____cm Hip:____cm Limbs: ____cm
Visual Acuity: ________Middle and Upper Arm Circumference:____cm
Blood Type: ________
PERTINENT FINDINGS PER SYSTEM:
A. HEENT C. HeartH. Neurological ExaminationG. Skin/Extremities
Essentially NormalEssentially normalEssentially normalEssentially normal
Abnormal pupillary reactionDisplaced apex beatAbnormal gaitClubbing
Cervical lympadenopathyHeaves/trillsAbnormal position senseCold clammy
Dry mucous membraneIrregular rhythmAbnormal sensationCyanosis/mottled skin
Icteric scleraeMuffled heart soundsAbnormal reflex(es)Edema/swelling
Pale conjunctivaeMurmursPoor/altered memoryDecreased mobility
Sunken eyeballsPericardial bulgePoor muscle tone/strengthPale nailbeds
Sunken fontanelleOthersPoor coordinationPoor skin turgor
OthersOthersRashes/Petechiae
Weak pulses
Others
B. Chest/Breast/Lungs D. AbdomenF. Digital Rectal ExaminationE. Genitourinary
Essentially normalEssentially normalEssentially normalEssentially normal
Asymmetrical chest expansionAbdominal rigidityEnlarge ProstateBlood stained in exam finger
Decreased breath soundsAbdominal tendernessMassCervical dilatation
WheezesHyperactive bowel soundsHemorrhoidsPresence of abnormal discharge
Lumps over breast(s)Palpable mass(es)PusOthers
Crackles/ralesTympanitic/dull abdomenNot Applicable
RetractionsUterine contractionOthers
OthersOthers