FORM 2

PHYSICAL HEALTH INVENTORY FORM

Instructions to Parents/Guardians: The following information is

required to a child attending the CDC for record and referral
purposes. Please complete Part I of the Health Assessment Form.
Part II must be completed by a private licensed physician/nurse,
Municipal/Rural/Barangay Health Unit Officer (M/R/BHUO), or
Barangay Nutrition Scholars (BNS). The Center ensures that each
child has access to a thorough health assessment

BASIC INFORMATION

Child’s Name: _______________________________________________________

Last First Middle

Birth Date: __________________________ Sex: M F

Address: ____________________________________________________________

___________________________________________________________________

Parent/Guardian Name(s)_______________________________________________
Relationship: ________________________
Phone Number(s): Work: ____________________ Home:
____________________
Mobile Number(s): ________________, _________________, _________________
Accomplished by : ______________________________ __________________
Signature over printed name of parent/guardian
Date

Physical Health Inventory Form Page 1

PART I – PHYSICAL HEALTH ASSESSMENT

To be completed by parent or guardian

Where do you usually take your child for routine check-up?

Name of Hospital/Center: ___________________________________________________

Address: _________________________________________ Phone No. ___________

When was the last time your child had a routine check-up? (mo/day/yr) &
Where?

Date: _________Name of Hospital/Center:

_____________________________________

ASSESSMENT OF CHILD’S HEALTH – To the best of your knowledge has

your child had any problem with the following? Check () Yes or No and
provide a comment for any YES answer.
YE NO Comments (required for any
S YES answer
Allergies (Food, Insects,
Medicine, etc.)
Asthma
Bleeding
Bowels
Coughing
Diabetes
Ears or Deafness
Eyes or Vision

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Other (please indicate)

Does your child take medication (prescription or non-prescription) at any

time?

Yes No, name(s) of medication(s):

_____________________________________

Does your child receive special treatment? (nebulizer, etc.)

Yes No, type of treatment:

____________________________________________

Does your child ever have a serious accident? Yes No, If yes
describe briefly:

________________________________________________________________________

I ATTEST THAT ALL INFORMATION PROVIDED ON THIS FORM IS TRUE

AND ACCURATE TO THE BEST OF MY KNOWLEDGE AND BELIEF. I
UNDERSTAND IT IS FOR CONFIDENTIAL USE IN MEETING MY CHILD’S
HEALTH NEEDS IN CDC.

Physical Health Inventory Form Page 3

Signature of Parent/Guardian Date

PART II – CHILD PHYSICAL HEALTH ASSESSMENT

To be completed ONLY by Physician/Nurse Practitioner,

Municipal/Rural/Barangay Health Unit Officer or Barangay Nutrition
Scholar

1. Does the child have diagnosed medical condition?

No Yes, describe: _____________________________________________

2. Does the child have health condition which may require EMERGENCY
ACTION while s/he is in the Center? (e.i. seizure, allergy, asthma,
bleeding problem, heart problem, or other problem) if yes, Please
DESCRIBE and describe emergency action(s).

No Yes, describe: ______________________________________________

_____________________________________________________________________

3. Physical Examination Findings

____________________________________________
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 _____________________________________________________________________
Health Area WNL ABNL
Not
(With Normal Limits) (Abnormal)
Evaluated

Allergy
Asthma
Attention Deficit/Hyperactivity
Bowel/Bladder
Cardiac/murmur
Dental
Endocrine
ENT
Hearing
Musculoskeletal/orthopedic
Neurological
Nutrition
Physical Illness/Impairment
Respiratory
Skin
Speech/Language
Vision
Other (please indicate)

Remarks: (Please explain any abnormal findings.)

_______________________________

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_______________________________________________________________________

_______________________________________________________________________

4. RECORDS OF IMMUNIZATIONS (please indicate full dates)

DPT: ______________ BCG: ____________ Polio: MMR: ________

_________

Hepa B: Measles: Others: _______________________

___________ _________

Others: (Please specify) ____________________________________________________

5. Is the child on medication?

No Yes, specify nature and duration:

_______________________________

Additional Comment: ______________________________________________________

________________________________________________________________________

Name of Medical Phone No.: Signature:

Practitioner:

Date: ____________________

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