BCYW - DCS FORM NO.

5
INITIAL AND ANNUAL HEALTH RECORD
(For use of the physician)

I. Maternal History: Please check illness/illnesses during pregnancy

¨ Goiter ¨ German Measles

¨ Diabetes ¨ Hepatitis
¨ Tuberculosis ¨ Sexually Transmitted Disease (STDs)
¨ Heart Disease ¨ Others (please specify):
_______________________________

II. Brief History

A. Type of Delivery
¨ Normal Spontaneous Delivery
¨ Caesarian Section
¨ Forcep

B. Place of Delivery
¨ Hospital
¨ Home
¨ Others (please specify): _________________________________

C. State Complications, if any: _____________________________________________________

D. Allergies, if any: ______________________________________________________________

III. Immunization
DATES GIVEN:
DPT ___________________ ___________________
POLIO ___________________ ___________________
BCG ___________________ ___________________
MEASLES ___________________ ___________________
TETANUS ___________________ ___________________
HEPATITIS B ___________________ ___________________

IV. Deworming
Date of last deworming
¨ YES ___________________ ___________________
¨ NO ___________________ ___________________
V. Disability/Impairment (please check if any):
¨ Congenital Deformities ¨ Emotional Disturbances
¨ Deafness ¨ Others (please specify):
¨ Speech Defect ______________________________

VI. Previous Illness/Illnesses Date:

___________________ ___________________
___________________ ___________________
___________________ ___________________
VII. Current Health Status
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________

VIII. Pertinent Physical Examination

HEENT __________________ GUT __________________

CHEST/LUNGS __________________ MUSCULAR __________________
ABDOMEN __________________ NEURO __________________

IX. Remarks
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________

_______________________
Signature of Physician

______________
Date