UHBI-PARAÑAQUE DOCTORS HOSPITAL, INC.

175 Doña Soledad Ave. Better Living Subdivision. Parañaque City

Contact Nos. 776-0644; 776-0654; 776-0651; 7760648; 776-0646; 7760645

WRITE IN ALL CAPITAL LETTERS. NO BLANKS. SUBMIT TO ICC ASAP. PLEASE

TEXT 0916-249-1149
CATEGORY:
01 – HEALTH CARE WORKER
02 – SENIOR CITIZEN
03 – INDIGENT
04 – UNIFROMED PERSONNEL
05 – ESSENTIAL WORKERS / HOSPITAL
STAFF
06 - OTHERS
CATEGORY ID NUMBER:
PHILHEALTH ID NUMBER
PWD ID NUMNER (IF ANY)
LASTNAME
FIRSTNAME
MIDDLENAME
SUFFIX
CONTACT NUMBER
HOUSE NUMBER AND STREET
PROVINCE NAME
CITY NAME
BARANGAY NAME
SEX
BIRTH DATE (MONTH/DATE/YEAR)
AGE
CIVIL STATUS
01 – Single
02 – Married
03 – Widow/Widower
04 – Separated/Annulled
05 – Living with Partner
STATUS OF EMPLOYMENT
01 – Government Employed
02 – Private Employed
03 – Self-employed
04 - Private practitioner
05 – Others
NAME OF PROFESSION
NAME OF EMPLOYER
ADDRESS OF EMPLOYER
CONTACT NUMBER OF EMPLOYER
IF FEMALE, PREGNANCY STATUS (YES
OR NO)
WITH ALLERGY
01 – Yes
 UHBI-PARAÑAQUE DOCTORS HOSPITAL, INC.
175 Doña Soledad Ave. Better Living Subdivision. Parañaque City
Contact Nos. 776-0644; 776-0654; 776-0651; 7760648; 776-0646; 7760645

02 – None
NAME OF ALLERGY
Name of Allergy
01 – Drug
02 – Food
03 – Insect
04 – Latex
05 – Mold
06 – Pet
07 – Pollen
WITH COMORBIDITIES (IBA PANG
SAKIT?)
01 – Yes
02 – None
NAME OF COMORBIDITIES
01 – Hypertension
02 – Heart disease
03 – Kidney disease
04 – Diabetes mellitus
05 – Bronchial Asthma
06 – Immunodeficiency state*
07 – Cancer
08 – Others
DIRECT INTERACTION WITH COVID
PATIENTS?
01 – Yes
02 – No
WERE YOU DIAGNOSED WITH COVID-
19?
01 – Yes
02 – No
DATE OF 1ST POSITIVE RESULT /
SPECIMEN COLLECTION?
(MONTH/DATE/YEAR)
CLASSIFICATION OF INFECTION
01 – Asymptomatic
02 – Mild
03 – Moderate
04 – Severe
05 – Critical
PROVIDED WITH ELECTRONIC
INFORMED CONSENT
01 – Yes
02 – No
03 – Unknown
UHBI-PARAÑAQUE DOCTORS HOSPITAL, INC.
175 Doña Soledad Ave. Better Living Subdivision. Parañaque City
Contact Nos. 776-0644; 776-0654; 776-0651; 7760648; 776-0646; 7760645