University of Northern Philippines

Department of Preventive, Family and Community Medicine

Family Health Care Program

P.F.C. CHART
Group #

Members

1 | Page
 Family Name

Index Patient’s First Name

Address

Latest Genogram

.
Date of Initial Contact
Reason for Admission to Program
Parameters (pls check)
A “No” in any of the parameters makes the patient not eligible for the FHCP Yes No
The patient has provided his/her written consent.
The patient and family members have no known criminal record.
The medical assessments and genogram are complete.
The patient has chronic illness or psycho-social problems needing long term care.
The services of the FHCP may be of benefit to the patient and family.
The patient’s case may contribute to the training of students.
The patient’s household has two or more members and will likely be in 3-5 years.
The patient’s residence is within the accepted area and will likely be in 3-5 years.
The patient has no identified Primary Care Physician.
Date of Admission to Program

Reason for Discharge from Program

Timely Termination of Care (i.e., Completed Care) (pls check)
requires ALL of the following: Yes No
Patient and family is satisfied with the Care.
Patient is not presently on home-based care.
Consultant consented for Discharge; and ordered on the PFC Chart.

Premature Termination of Care (i.e., Discontinuation) (pls check)

requires ANY of the following: Yes No
Care has completed at least 3 years, at most 5 years of FHCP enrolment
Family’s change of address to beyond accessibility
Patient’s or any family member’s decision to discontinue Care
Index patient’s consistent non-cooperation for home visits/ eKonsulta/
OPD follow-up
Index patient’s demise
Most, if not all, Long-term goals are achieved (relative indication for termination)

Date of Case Audit and Discharge

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 Latest P.F.C. MATRIX
SUMMARY OF PATIENT-CENTERED ASSESSMENTS AND GOALS
Biomedical Psycho-Social Aspect Targets/ Goals of Care
Assessment/s • Trajectory Stage in FHCP Enrolment
• Limitations to Care
1. •
2. •
Index Patient
3. •
4. •
1. •
Family Member 1
2. •
Relation to Index Patient
3. •
PATIENT-CENTERED CARE

4. •
1. •
Family Member 2
2. •
Relation to Index Patient
3. •
4. •
1. •
Family Member 3
2. •
Relation to Index Patient
3. •
4. •
1. •
Family Member 4
2. •
Relation to Index Patient
3. •
4. •
1. •
Family Member 5
2. •
Relation to Index Patient
3. •
4. •

3 | Page
 Latest P.F.C. MATRIX
SUMMARY OF FAMILY-FOCUSED ASSESSMENTS, IMPACT AND GOALS
Family Assessment Findings Impact to Illnesses & Targets/ Goals of Care
Tool Used Care in the Family in FHCP Enrolment
Genogram 1.
& Profile 2.
Family
• Category 3.
Structure
• Roles 4.
5.
No. of health-carers 6.
Intra- Means of:
familial • Telecomm 7.
Resources • Transportation 8.
Budget Balance 9.
F-APGAR-1
• Total Score 10.
FAMILY-FOCUSED CARE

• Poor Domains 11.

12.
Abnormal Relations 13.
Family in the F-APGAR-2 14.
Psycho- and/or Family Map 15.
dynamics 16.
17.
Biography
• Bonds formed 18.
• Unresolved 19.
Issues 20.
Existing Parameter/s 21.
of Crowdedness
Infection Risk/ 22.
Hygiene 23.
Internal 24.
Environ- 25.
ment 26.
27.
Fall Risk 28.
Disaster Risk 29.
30.

4 | Page
 Latest P.F.C. MATRIX
SUMMARY OF COMMUNITY-ORIENTED ASSESSMENTS, IMPACT AND GOALS
Family and Findings Impact to Illnesses & Targets/ Goals of Care
Community Care in the Family in FHCP Enrolment
Assessment Tool
Used
Environmental risks
• Air Pollution 1.
• Water Pollution 2.
• Solid Waste 3.
• Communicable 4.
Diseases 5.
Neighbor- 6.
hood and Security/ Criminality 7.
Environ- 8.
ment Available public 9.
transport 10.
11.
Natural Disaster 12.
Risks 13.
14.
Tobacco Use 15.
NHIP membership 16.
Accessible HCP
• ITRMC 17.
• SDN facility 18. .
Healthcare • Local HC 19.
• BHW’s home 20.
COMMUNITY-ORIENTED CARE (Social Determinants)

Priority Sources of 21.

Health Information 22.
23.
DRRM Measures 24.
SCREEM-RES
• Total Score 25.
• Poorest 26.
Domains 27.
28. .
SCREEM 29.
• Resources 30.
SCREEM 31.
• Pathologies 32.
Eco-Map
• Flow-in 33.
Social and 34.
community • Flow-out 35.
context 36.
Financial Support
• Indigence 37.
• NGOs 38.
Outreach
39.
40.
41.
Local Health 42.
Programs 43.
Societal 44. .
Discriminations 45.
Literacy Rate 46.
Educational 47.
Education opportunities 48.
Scholarships to 49.
higher education 50.
Livelihood 51.
Economic
opportunities 52.
stability
Employment 53.
opportunities 54.
Access to healthful 55.
food choices 56.
Food
Malnutrition 57.
58.
.

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 PHYSICIAN’S ORDERS for Index Patient
INDEX PATIENT’S NAME: ___________________________________________________
Date, Assessments/ Status
Wellness and Therapeutic Orders
Time Progress Notes

6 | Page
.

PHYSICIAN’S ORDERS for Family/ Community

For positive findings of Family and Community Assessment Tools
Date, Assessments/ Status
Therapeutic Orders and Family Meetings
Time Progress Notes

7 | Page
.

M.D. Notes for Patient-centered Care

(Data Gathering Tool for each member of the family)

FULL NAME: ______________________________________________________

Clinical History
Date of Assessment: Age/ Sex:

Chief Complaint:

History of Present Illness:

Positive Review of Systems:

Past Medical History not related to HPI:

Obstetrical History and LMP/PMP: Vaccination History:

Nutrition History: Physical Activities:

Smoking History: Alcohol Misuse:

Occupation and Hazards: Social Support System:

Sexual History: Stresses:

8 | Page
Continued…
Physical Examination
Blood Pressure: HR (bpm): RR (cpm): Temp (Celsius): Pain VAS:

General:

Skin:

Head:

Eyes:

ENT:

Neck:

Chest:

Heart:

Abdomen:

Genito-urinary:

Ano-rectal:

Extremities:

Continued…

9 | Page
Neurologic:
GCS: NIHSS Score:

Cranial Nerve Deficits:

Cerebellum:

Peripheral System:
Sensory (%) Motor (over 5) DTRs (plus)

.
Positive Meningeal Signs:

Positive Abnormal Reflexes (e.g., Babinski):

.
MMSE Score:
• Orientation to Time and Place:

• Registration:

• Attention and Calculation:

• Delayed Recall:

• Language
o part a:
o part b:
o part c:
o part d:
o part e:
o part f:

Clock Drawing Test:

Other Psychiatric Tools:

10 | Page
Continued…
[Highlight the appropriate table and age-group for each member of the family]

11 | Page
 M.D. Notes for Family-focused Care
(Data Gathering Tool for the family as a whole)
FAMILY STRUCTURE
Genogram (see appendix for symbols)
Family Name
Date written
(overlap genogram here)

Generation 1

Generation 2

Generation 3

.
Legend
(illnesses)
Family Profile
Category of Extension Ο Away from family Ο Lineal
Family Ο Nuclear Ο Joint
(please check Ο Unilaterally Extended Ο Blended
appropriately Ο Bilaterally Extended Ο Family/ Kin Network
along each Marriage Ο Church marriage Ο Same-sex
row) Ο Legal marriage Ο Unmarried couple
Parenthood Ο Single parenting Ο Foster parenting
Ο Adoptive parenting Ο Others: ___________
Family Breadwinner/s
member/s Health-carer/s
who assume/s Decision-maker: External affairs
the role of: Internal affairs
Life Cycle Present Stage
Stage (see Unresolved Emotional Process of Transition
appendix for Unaccomplished Changes in Family Status
stages and
descriptions)

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 INTRA-FAMILIAL RESOURCES
Number of Health Carers (see Structure)
Means of:
•
Telecommunication •
•
•
Transportation •
•
Budget Balance
Incomes Prioritized Expenses

Total: PhP Total: PhP

FAMILY PSYCHODYNAMICS
Family APGAR 1 (see Green Chart appendix for questionnaire and interpretation)
Total Score: Interpretation:

Domain subscale Scores

Adaptation: Partnership: Growth: Affection: Resolve:

.
Family APGAR 2 (see Green Chart appendix for questionnaire and interpretation)
Family Member Relation to patient Family APGAR 2 Score

.
Family Map (see Green Chart appendix for instructions)

Family Biography (i.e., family anamnesis)

Significant happy events are above the arrow.

13 | Page
Depressing/ problematic events are below the arrow.
Birth of
Family
(year)

Day of
Consult

INTERNAL ENVIRONMENT
Crowdedness (WHO Expert Committee on the Public Health Aspects of Housing, 1991)
1. Absence of a sufficient number of rooms, usable floor area and volume of enclosed
space to satisfy human requirements for health and for family life, consistent with
the prevailing cultural and social pattern of that region and so utilized that living or
sleeping rooms are not overcrowded
2. for individual persons within the household
Absence of a minimum
3. for household members against undue external
degree of desired privacy:
disturbance
4. sleeping areas for adolescent and adult members of
Absence of suitable
the opposite sex; except husband and wife
separation of rooms used
5. domestic animals apart from the living room of dwelling
for:
unit
Infection Risks/ Hygiene; Fall Risk; Disaster Risk
Pests observed (Vermin,
vectors and vehicles of
infections)
Pets or Livestock present
Food safety methods
Water safety methods
Human waste disposal
Solid waste disposal
Fall hazards
Fire hazard including
electrical hazards
Drainage (if flood-prone)

Family and Findings Impact to Illnesses & Targets/ Goals of Care

Community Care in the Family in FHCP Enrolment
Assessment Tool
Used

14 | Page
 Environmental risks
• Air Pollution 59.
• Water Pollution 60.
• Solid Waste 61.
• Communicable 62.
Diseases 63.
Neighbor- 64.
hood and Security/ Criminality 65.
Environ- 66.
ment Available public 67.
transport 68.
69.
Natural Disaster 70.
Risks 71.
72.
Tobacco Use 73.
NHIP membership 74.
Accessible HCP
• ITRMC 75.
• SDN facility 76. .
Healthcare • Local HC 77.
• BHW’s home 78.
COMMUNITY-ORIENTED CARE (Social Determinants)

Priority Sources of 79.

Health Information 80.
81.
DRRM Measures 82.
SCREEM-RES
• Total Score 83.
• Poorest 84.
Domains 85.
86. .
SCREEM 87.
• Resources 88.
SCREEM 89.
• Pathologies 90.
Eco-Map
• Flow-in 91.
Social and 92.
community • Flow-out 93.
context 94.
Financial Support
• Indigence 95.
• NGOs 96.
ITRMC Outreach
• CBHP/ COPC 97.
• Other dept 98.
99.
Local Health 100.
Programs 101.
Societal 102. .
Discriminations 103.
Literacy Rate 104.
Educational 105.
Education opportunities 106.
Scholarships to 107.
higher education 108.
Livelihood 109.
Economic
opportunities 110.
stability
Employment 111.
opportunities 112.
Access to healthful 113.
food choices 114.
Food
Malnutrition 115.
116.

15 | Page
 M.D. Notes for Community-oriented Care
(Data Gathering Tool for the family in the context of its community)
EXTRA-FAMILIAL RESOURCES
SCREEM-RES (see Green Chart appendix for questionnaire and interpretation)
Interviewee: Total Score: Interpretation:

Domain subscales Scores: Domain subscales Scores:

• Social: ________________ • Economic: ________________
• Cultural: ________________ • Educational: ________________
• Religious: ________________ • Medical: ________________
SCREEM
Extra-familial Resources Extra-familial Pathologies
Social

Cultural

Religious

Economic

Educational

Medical
Eco Map (extra-familial institutions that describe the flow of resources of the family)

3 4

2 5

Family
1 6
Name

Community Financial Support System

NHIP Membership: Indigence: NGO Beneficiary
Ο Yes Ο Yes, certified Ο Yes
Ο No Ο Yes, not certified (NGO name: __________)
Ο No Ο No
Accessibility of Healthcare
Geographical distance of the family’s house to: (meters)
• Hospital/ RHU
• Nearest ER
• Nearest SDN facility
• Nearest non-SDN Local Health Center
• Barangay Health Worker’s home

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Sources of Health Information
Rank the top 3 sources of
information with numbers 1 to 3
Physicians Ο Yes Ο No
Public Health (DOH)
Ο Yes Ο No
Announcements
Nurses Ο Yes Ο No
Barangay Health Workers and local
Ο Yes Ο No
health center
Internet and Social Media Ο Yes Ο No
Television Shows Ο Yes Ο No
Radio Programs Ο Yes Ο No
EXTERNAL OPPORTUNITIES

Remarks
Local Health Programs Ο Yes Ο No
DRRM Measures Ο Yes Ο No
Target community if applicable Ο Yes Ο No
ENVIRONMENTAL RISKS/ THREATS
.
Remarks
Air Pollution Ο Yes Ο No
Allergens (if app) Ο Yes Ο No
Water Pollution Ο Yes Ο No
Solid Waste Ο Yes Ο No
Nature Disaster Risk Ο Yes Ο No
Security/ Criminality Ο Yes Ο No
.
TRIPLE BURDEN OF ILLNESS
.
Remarks
Endemic Communicable Diseases Ο Yes Ο No
Non-communicable Diseases
• Smokers Ο Yes Ο No
• Sedentary Lifestyle Ο Yes Ο No
.

Written Consent for Care

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Updated every 6 months, this informed consent for the family _____________ (surname)
of Ilocos Sur within the jurisdiction of the Family Healthcare Program of the University of
Northern Philippines Department of Preventive, Family and Community Medicine who
after review of the family case, is admitted into the Program’s care.
Student’s in-charge: ____________________________________________
____________________________________________
____________________________________________
____________________________________________

(Read audibly and clearly to the member/s of the family)

Part 1. Mga Mahalagang Impormasyon

Ako po si Doctor (pangalan) mula sa Family Healthcare Program of the University of Northern
Philippines Department of Preventive, Family and Community Medicine
Ako po ay nandito para magbigay ng impormasyon at makuha ang inyong permiso upang kayo
ay makalahok sa pangangalaga ng Family Health Care Program ng Department of Preventive,
Family and Community Medicine.
Hindi ninyo po kailangan na magdesisyon agad ngayon kung papayag po kayo o hindi.
Pwede po kayo magtanong muna sa mga taong kakilala ninyo bago kayo magdesisyon.
Habang nagpapaliwanag, pakisabihan lang po ako na huminto kung may mga tanong po kayo.

Ang Pangangalaga na ito ay para matulungan po kayong matugunan ang inyong mga
pangangailangang medikal sa susunod na 3 hanggang 5 taon. Ito rin po ay para makatulong sa
pag-aaral ng mga student doctors ng Medisina upang maging mas magaling na mga doctor. Ang
mga ito ay alinsunod sa mga layunin ng programa na:
• Magbigay ng kasiya-siyang pangangalagang medikal sa pasyente at kanyang pamilya.
• Mapanatili ang pinakamabuti, nababatay sa huling katibayan at etikal na pangangalaga.
• Maiwasan ang maagang di-kanais-nais na epekto ng karamdaman ng pasyente.
• Makapaglaan ng mga kasong makakatulong sa pagsasanay ng mga doktor.
• Makatulong sa mga estudyante upang maintindihan ang tinaguriang “family-oriented care”.

Ang Pangangalagang na ito ay gagawin sa pamamagitan ng mga paulit-ulit na konsultasyon at

physical examination sa inyo at sa mga miyembro ng inyong tahanan. Ito ay may kaakibat na
serbisyong medikal kasama dito ang:
• Libreng konsultasyon sa doktor at referral sa kailangang spesyalista
• Libreng reseta
• Libreng abisong pang-nutrisyon

Kayo po ay napili para sa Pangangalaga matapos pong mapag-aralan ng aming mga

Consultants na si (Consultants’ names) ang inyong kalagayan.

Ang desisyon ninyo para sa Pangangalaga ay hindi magdudulot ng kabawasan sa serbisyong

medikal na binibigay sa inyo ng ITRMC Department of Community and Family Medicine. Hindi
rin ito magdudulot ng masamang epekto sa ibang aspeto kagaya ng diskriminasyon.

Ang Pangangalaga na ito ay magtatagal ng kulang-kulang sa 3 hanggang 5 taon, maliban na

lamang kung mapagdesisyonan po ninyong ihinto ito. Lahat po ng malalamang impormasyon sa
Pangangalaga ay papanatilihing confidential, alinsunod sa Data Privacy Act of 2012 ng ating
bansa (RA 10173) ; at ako, ang aming mga Consultant na si (Consultants’ names) kasama ng
kanyang mga estudyante ang tanging makakaalam. Pagkatapos nito at sisirain ang lahat ng
papeles at files na naglalaman ng mga impormasyon

Lahat ng mga karapatan ninyo bilang pasyente alinsunod sa Filipino Patient’s Bill of Rights ng
Batas, ay poprotektahan.

18 | Page
 Ang Pangangalaga na ito ay maaaring magdulot ng banayad na kalungkutan lalo kung sensitibo
ang mga impormasyon, bukod pa sa gagamiting oras ninyo.
Bilang bahagi ng pagsasanay ng mga estudyante, ang Pangangalaga na ito ay
mangangailangan ng pagpapaulit-ulit ng interbyu at eksaminasyon. Maaari po ninyo kaming
sabihan kung ito ay nagdudulot na ng di kaaya-ayang pakiramdam sa inyo upang ito ay kaagad
na maihinto.

Wala pong direktang benepisyong pinasyal o bayad para sa inyo ang Pangangalaga.

Kayo ay may karapatang ipahinto ang proseso ng Pangangalaga anumang oras na inyong
gusto. Kayo rin ay may karapatang ipatanggal ang inyong pangalan at mga impormasyon sa
kahit anumang dahilan.

Kung may mga problema, di kanais-nais na pangyayari o anumang tanong na may kinalaman sa
Family Health Care Program, maaari po kayong tumawag sa University of Northern Philippines
Department of Preventive, Family and Community Medicine.

Part 2. Ang Pagpayag sa Pakikilahok

Ako ay pinaliwanagan ng mabuti, binigyan ng pagkakataong magtanong at ang mga tanong ko,
kung mayroon, ay sinagot sa abot ng aking pag-iintindi.
Ako ay pumapayag na lumahok sa Pangangalaga.
Pangalan ng Pasyente: ____________________________________________
Lagda ng Pasyente: ____________________________________________
Petsa: ____________________________________________
Ako ay nagbasa ng Consent na ito at ipinaliwanag sa pasyente, binigyan siya ng pagkakataong
magtanong at sinagot ko ang kanyang mga tanong sa abot ng kanyang pag-iintindi. Ako ay
nagpapatunay na hindi siya pinilit sa anumang paraan para sa kanyang paglahok.
Ang pasyente ay bibigyan ng kopya ng Consent na ito.
Pangalan ng Estudyante: ____________________________________________
Lagda ng Estudyante: ____________________________________________
Petsa: ____________________________________________

Reference: World Health Organization Templates for Informed Consent

19 | Page
 Appendices
Detailed Guide for Promotive and Preventive Care
(Screening Methods, Vaccinations and Chemoprevention/ Prophylaxis)
.
Screening Methods for Children and Adolescents
Frequency of
Age Risk factors Illness Screening tool
screening
All Sexually active Chlamidial NAAT Every 1 year
Infection
All Sexually active, and with history of previous Gonorrhea Cervico-vaginal (var)
gonorrhea infection, other sexually transmitted culture, or
infections, new or multiple sexual partners, NAAT
inconsistent condom use, sex work, and drug use
All MSM (or MSMW) or HIV-AIDS Reactive (var)
Active injection drug users, or immune-assay
Have acquired or request testing for other plus Western
sexually transmitted infections, or Having Blot
unprotected vaginal or anal intercourse, or
Having sexual partners who are HIV-infected,
bisexual, or injection drug users, or
Exchanging sex for drugs or money
2-4 --- CH, CAH, PKU, Expanded NBS Once
days G6PD
age deficiency,
GAL, MSUD
Within --- Hearing loss otoacoustic Once
1 emissions
month followed by
age auditory brain
stem response
Within --- Sickle cell HPLC or thin- Once
2 disease layer IEF
month
age
3-5 --- Visual Visual acuity (var)
years impairment test, or stereo-
acuity test, or
cover-uncover
test, etc
6-18 --- Obesity BMI (var)
years
12-18 When systems for diagnosis, treatment and Major PHQ-A or BDI- (var)
years follow-up are in place depressive PC
disorder
.
Screening Methods for Male Adult
Age in Frequency of
Risk factors Illness Screening tool
years screening
All When staff-assisted depression care supports are Depression PHQ or other (var)
available tools
All BP > 135/80 T2DM FBS, 2hPPG or Every 3 years
A1c
All History of IV drug abuse; or receiving a blood HCV infection Anti-HCV (var)
transfusion before 1992, long-term hemodialysis,
being born to an HCV-infected mother,
incarceration, intranasal drug use, getting an
unregulated tattoo, and other percutaneous
exposures
All Last BP measured at <120 / 80 HTN BP measure Every 2 years
Last BP measured at 120-139 / 80-90 Every 1 year
All MSM (or MSMW) or HIV-AIDS Reactive (var)
Active injection drug users, or immune-assay
Have acquired or request testing for other plus Western
sexually transmitted infections, or Having Blot
unprotected vaginal or anal intercourse, or
Having sexual partners who are HIV-infected,
bisexual, or injection drug users, or
Exchanging sex for drugs or money
All --- Obesity BMI (var)
All --- Smoking 5-A’s (var)

20 | Page
 20-35 With diabetes, history of previous CHD or Lipid disorders TC, TG, HDL, Every 5 years
atherosclerosis, family history of cardiovascular LDL (non- until 65 years
disease, tobacco use, hypertension, and obesity fasting or old
(body mass index ≥30 kg/m2). fasting),
> 35 --- repeated if
abnormal
.
Screening Methods for Reproductive-aged, Non-pregnant Female
Age in Frequency of
Risk factors Illness Screening tool
years screening
All Family history for breast cancer diagnosis before BRCA Genetic (var)
age 50 years, bilateral breast cancer, family mutations counselling
history of breast and ovarian cancer, presence of and/or testing
breast cancer in ≥1 male family member, multiple
cases of breast cancer in the family, ≥1 or more
family member with 2 primary types of BRCA-
related cancer, and Ashkenazi Jewish ethnicity
All When staff-assisted depression care supports are Depression PHQ or other (var)
available tools
All BP > 135/80 T2DM FBS, 2hPPG or Every 3 years
A1c
All Sexually active, and with history of previous Gonorrhea Cervico-vaginal (var)
gonorrhea infection, other sexually transmitted culture, or NAAT
infections, new or multiple sexual partners,
inconsistent condom use, sex work, and drug use
All History of IV drug abuse; or receiving a blood HCV infection Anti-HCV (var)
transfusion before 1992, long-term hemodialysis,
being born to an HCV-infected mother,
incarceration, intranasal drug use, getting an
unregulated tattoo, and other percutaneous
exposures
All Active injection drug users, or HIV-AIDS Reactive (var)
Have acquired or request testing for other immune-assay
sexually transmitted infections, or Having plus Western
unprotected vaginal or anal intercourse, or Blot
Having sexual partners who are HIV-infected,
bisexual, or injection drug users, or
Exchanging sex for drugs or money
All --- Intimate History (var)
partner
violence
All --- Obesity BMI (var)
All Fracture risk using the FRAX fracture risk Osteoporo-sis DEXA of hip and (var)
assessment tool is equal to or greater than that of lumbar spine
a 65-year-old white woman without additional risk
factors
All --- Smoking 5-A’s (var)
18-24 Sexually active Chlamidial NAAT Every 1 year
25-50 Previous chlamydial infection or other sexually Infection
transmitted infections, new or multiple sexual
partners, inconsistent condom use, sex work
20-35 With diabetes, history of previous CHD or Lipid disorders TC, TG, HDL, Every 5 years
atherosclerosis, family history of cardiovascular LDL (non-fasting until 65 years
disease, tobacco use, hypertension, and obesity or fasting), old
(body mass index ≥30 kg/m2). repeated if
> 35 --- abnormal
21-50 --- Cervical Pap smear Every 3 years
cancer
30-50 Pap smear + Every 5 years
HPV testing
40-49 Patient age, race/ethnicity, age at menarche, age Breast cancer Film mammo- 2x a year
at first live childbirth, personal history of ductal or graphy
lobular carcinoma in situ, number of first-degree
relatives with breast cancer, personal history of
breast biopsy, body mass index, menopause
status or age, breast density, estrogen and
progestin use, smoking, alcohol use, physical
activity, and diet.

Screening Methods for the Pregnant

Age in Frequency of
Risk factors Illness Screening tool
years screening
All 12-16 weeks AOG or at first prenatal visit if later Asymptom-atic urine culture (var)
bacteriuria

21 | Page
 All When staff-assisted depression care supports are Depression PHQ or other (var)
available tools
All BP > 135/80 T2DM FBS, 2hPPG or Every 3 years
A1c
All > 24 weeks AOG GDM 50g OGCT or Once every
75g OGTT pregnancy
All Sexually active, and with history of previous Gonorrhea Cervico-vaginal First prenatal
gonorrhea infection, other sexually transmitted culture, or visit (plus 3rd
infections, new or multiple sexual partners, NAAT trimester)
inconsistent condom use, sex work, and drug use
All --- HBV Infection HBsAg First prenatal
visit
All History of IV drug abuse; or receiving a blood HCV infection Anti-HCV First prenatal
transfusion before 1992, long-term hemodialysis, visit
being born to an HCV-infected mother,
incarceration, intranasal drug use, getting an
unregulated tattoo, and other percutaneous
exposures
All Active injection drug users, or HIV-AIDS Reactive (var)
Have acquired or request testing for other immune-assay
sexually transmitted infections, or Having plus Western
unprotected vaginal or anal intercourse, or Blot
Having sexual partners who are HIV-infected,
bisexual, or injection drug users, or
Exchanging sex for drugs or money
All --- Syphilis VDRL and RPR Prenatal visit-1
All Uninsured women, or women living in poverty, or Syphilis Repeat VDRL 3rd trimester
sex workers, or illicit drug users, or diagnosed and RPR and at delivery
with other sexually transmitted infections (STIs),
or other women living in communities with high
syphilis morbidity
All --- Smoking 5-A’s (var)
All --- Iron defi-ciency Hgb and Hct First prenatal
anemia visit
21-50 --- Cervical cancer Pap smear Every 3 years
30-50 Pap smear + Every 5 years
HPV testing
18-24 --- Chlamidial NAAT Every 1 year
25-50 Previous chlamydial infection or other sexually Infection
transmitted infections, new or multiple sexual
partners, inconsistent condom use, sex work
.
Screening Methods for Male Elderly
Age in Frequency of
Risk factors Illness Screening tool
years screening
All When staff-assisted depression care supports are Depression PHQ or other (var)
available tools
All BP > 135/80 T2DM FBS, 2hPPG or Every 3 years
A1c
All --- Obesity BMI (var)
All --- Smoking 5-A’s (var)
50-75 --- Colorectal High-sens Every 1 year
cancer FOBT
sigmoido-scopy Every 5 years
with FOBT
q3yrs
colono-scopy Every 10 years
50-65 --- Lipid disorders TC, TG, HDL, Every 5 years
LDL (non- until 65 years
fasting or old
fasting),
repeated if
abnormal
> 53 Adults born between 1945 and 1965; or history of HCV infection Anti-HCV Once in lifetime
IV drug abuse; or receiving a blood transfusion
before 1992, long-term hemodialysis, being born
to an HCV-infected mother, incarceration,
intranasal drug use, getting an unregulated tattoo,
and other percutaneous exposures
55-80 30 pack years smoking history, or Lung cancer Low-dose chest Every 1 year
presently smoking, or have quit within the last 15 CT scan
years

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 65-75 Ever-smoked abdominal abdominal once in lifetime
aortic ultrasound
aneurysm
< 66 MSM (or MSMW) or HIV-AIDS Reactive (var)
Active injection drug users, or immune-assay
Have acquired or request testing for other plus Western
sexually transmitted infections, or Having Blot
unprotected vaginal or anal intercourse, or
Having sexual partners who are HIV-infected,
bisexual, or injection drug users, or
Exchanging sex for drugs or money
.
Screening Methods for Menopausal
Age in Frequency of
Risk factors Illness Screening tool
years screening
All Family history for breast cancer diagnosis before BRCA Genetic (var)
age 50 years, bilateral breast cancer, family mutations counselling
history of breast and ovarian cancer, presence of and/or testing
breast cancer in ≥1 male family member, multiple
cases of breast cancer in the family, ≥1 or more
family member with 2 primary types of BRCA-
related cancer, and Ashkenazi Jewish ethnicity
All Sexually active Chlamidial NAAT Every 1 year
Infection
All When staff-assisted depression care supports are Depression PHQ or other (var)
available tools
All BP > 135/80 T2DM FBS, 2hPPG or Every 3 years
A1c
All --- Obesity BMI (var)
All --- Osteoporo-sis DEXA of hip (var)
and lumbar
spine
All --- Smoking 5-A’s (var)
50-65 --- Lipid disorders TC, TG, HDL, Every 5 years
LDL (non- until 65 years
fasting or old
fasting),
repeated if
abnormal
50-74 Patient age, race/ethnicity, age at menarche, age breast cancer Film mammo- Every 2 years
at first live childbirth, personal history of ductal or graphy
lobular carcinoma in situ, number of first-degree
relatives with breast cancer, personal history of
breast biopsy, body mass index, menopause
status or age, breast density, estrogen and
progestin use, smoking, alcohol use, physical
activity, and diet.
50-75 --- Colorectal High-sens Every 1 year
cancer FOBT
sigmoido-scopy Every 5 years
with FOBT
q3yrs
colono-scopy Every 10 years
51-65 --- Cervical cancer Pap smear Every 3 years
PS+HPV test Every 5 years
> 53 Adults born between 1945 and 1965; or history of HCV infection Anti-HCV Once in lifetime
IV drug abuse; or receiving a blood transfusion
before 1992, long-term hemodialysis, being born
to an HCV-infected mother, incarceration,
intranasal drug use, getting an unregulated tattoo,
and other percutaneous exposures
55-80 30 pack years smoking history, or Lung cancer Low-dose chest Every 1 year
presently smoking, or have quit within the last 15 CT scan
years
> 65 History of falls, history of mobility problems, and Falls Comprehen- Once in lifetime
poor performance on the timed Get-Up-and-Go sive multi-
test. factorial A>
< 66 Active injection drug users, or HIV-AIDS Reactive (var)
Have acquired or request testing for other immune-assay
sexually transmitted infections, or Having plus Western
unprotected vaginal or anal intercourse, or Blot
Having sexual partners who are HIV-infected,
bisexual, or injection drug users, or
Exchanging sex for drugs or money

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Vaccinations for Immunocompetent Children

Vaccinations for Immunocompetent Adults

Vaccinations for Special Populations

24 | Page
 Chemoprevention and Prophylaxis
Prevented
Group Age Risk factors Strategy
Illness
All 10-24 years Fair skin type Skin Cancer Behavioral
Counselling on
minimizing
exposure to UV
radiation
Neo- Within 24 --- Gonococcal 0.5%
nates hours of life ophthalmia erythromycin
neonatorum ophthalmic
ointment, 1.0%
solution of silver
nitrate, and 1.0%
tetracycline
ointment; applied
once
Infants 6-12 months Increased risk for IDA Iron-deficiency Iron-fortified
age anemia formula or iron
supplements
Child-ren School age Parental smoking and parental nicotine Smoking Behavioral
and Adoles- dependence, or low levels of parental interventions
cents monitoring, or easy access to cigarettes, or
perception that peers smoke, or exposure to
tobacco promotions
Adoles- All Sexually active STI’s Behavioral
cents Counselling
Men and All Current STI, or history of STI within the past 1
Women year, or have multiple sexual partners
Men and > 18 years --- Cardio-vascular Behavioral
Women Diseases Interventions for
Healthful Diet
and Physical
Activity
Women Reproduc- Plan to get pregnant in the next 1 month or Fetal neural tube Folic Acid
tive age later defects 400mgtab 1-
2tabs OD x first
2-3 months of
pregnancy
Men 45-79 years Potential for CVD benefit (ASCVD 10-year risk) Myocardial ASA 80mgtab 1
outweighs risk of GI hemorrhage (history of infarction tab OD
NSAID use, GI ulcers, upper GI pain)
Women 45-79 years Potential for CVD benefit (ASCVD 10-year risk) Stroke ASA 80mgtab 1
outweighs risk of GI hemorrhage (history of tab OD
NSAID use, GI ulcers, upper GI pain)
Men and > 65 years High risk for falls according to Comprehensive Falls exercise/
Women multifactorial assessment physical therapy
vitamin D tab (ie,
600 IU for <71
years old; 800 IU
for >70 years old)
.

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Genogram symbols
Symbol Definition Symbol Definition
Living Heterosexual
Married
Male
Living Heterosexual
Live-in or Affair
Female
Live-in or Affair,
Dead Male then Separated,
then had another

Dead Female Legally Separated

Legally Separated,
Living Homosexual
then had a Live-in
Male
or Affair
Living Homosexual Divorced (in another
Female country)

Spontaneous Biological Female

Abortion Child

A Adopted Female
Induced Abortion
Child

Dizygotic twin
Still-born
females

Monozygotic twin
Pregnancy in-utero
females

(points to Index (encircles members

Patient) of Household)

26 | Page
Family Life Cycle Stages
Emotional Process of Changes in Family Status required to
Stage
Transition Proceed Developmentally
• Differentiation of self in relation to the
Accepting financial family of origin
Unattached and emotional • Development of intimate peer
I
young adult responsibility for relationships
oneself • Establishment of self in relation to
work, and financial independence
• Formation of the marital system
Newly
Commitment to the • Realignment of relationships with
II married
new system extended families and friends to
couple
include the spouse
• Adjusting the marital system to make
space for children
Family with Accepting new • Joining in child-rearing, and financial
III young members into the and household tasks
children system • Realignment of relationships with the
extended family to include parenting
and grand-parenting roles
Increasing flexibility of • Shifting of parent-child relationships to
family boundaries to permit adolescents to move in and out
Family with
IV include children’s of the system
adolescents
independence, and • Focus on mid-life marital and career
1st child grand-parent’s frailties issues
• Beginning shift toward joint caring for
the older generation
• Renegotiation of marital system as a
dyad
Accepting a multitude • Development of adult-to-adult
Launching
V of exits from and relationships between grown-up
family
entries into the system children and their parents
1st chic • Realignment of relationships to include
in-laws and grandchildren
beams home • Dealing with disabilities and death of
grand-parents
• Maintaining own and/or couple
functioning and interests in the face of
physiologic decline; exploration of new
familial and social role options
• Support for a more central role of
Family in
middle generation
later life Accepting the shifting
VI • Making room in the system for the
(empty of generational roles
wisdom and experience of the elderly
nest)
last child and supporting the older generation
• Dealing with the loss of spouse,
leaves siblings, peers; preparation for one’s
own death
home • Life review and integration
.

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SCREEM-RES questionnaire
(adopted from Medina Jr MD, SCREEM Family Resources Survey, UP-PGH-SHPM, 2010)

Instruct the patient or main internal decision-maker or main breadwinner to place a check
on the column of their answers to the questionnaire. Do not explain the questions (self-
administered).

Questionnaire
Matinding
Matinding Hindi
Sumasang- Hindi
Kapag may nagkakasakit sa sumasang- Sumasang-
ayon Sumasang-
ayon ayon
aming pamilya… ayon
S1 Kami ay nagtutulngan sa isa’t isa
sa aming pamilya.
S2 Natutulungan kami ng aming mga
kaibigan at kasamahan sa
komunidad
C1 Ang aming kultura ay nagpapatatag
ng loob ng aming pamilya.
C2 Ang kultura ng pagtutulungan at
pagmamalasakit sa aming
komunidad ay nakakatutulong sa
aming pamilya.
R1 Ang aming pananampalataya at
relihiyon ay nakakatulong sa aming
pamilya.
R2 Natutulungan kami ng aming mga
kasamahan sa simbahana o gmga
grupong relihiyoso.
E1 Sapat ang naipong pera ng aming
pamilya para sa aming mga
pangangailangan.
E2 Sapat ang kinikita ng aming
pamilya para sa aming
pangangailangan.
E’1 Sapat ang aming kaalaman upang
maintindihan ang mga
impormasyon tungkol sa sakit.
E’2 Sapat ang aming kaalaman upang
maalagaan ang maysakit.
M1 Madaling makakuha ng tulong
medikal sa aming komunidad.
M2 Natutulungan kami ng mga doktor,
nars, at health workers sa aming
komunidad.

SCREEM-RES Interpretations:
Total Score 0 to 12 means Severely Inadequate Family Resources
interpretations 13 to 24 means Moderately Inadequate Family Resources
25 to 36 means Adequate Family Resources
Domain subscale 0 to 2 means Severely Inadequate Domain
Score interpretations 3 to 4 means Moderately Inadequate Domain
5 to 6 means Adequate Domain

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Family APGAR 1 questionnaire
(adopted from Smilkstein, translated by Medina Jr MD, The Family APGAR, PAFP Filipino
Version, UP-PGH-SHPM, 2011)
Paminsan-
Palagi Halos Hindi
Tungkol sa aking pamilya… minsan
A Ako’s nasisiyahan dahil nakakaasa
ako ng tulong sa aking pamilya sa
l

oras ng problema.
P Ako’y nasisiyahan sa paraang
nakikipagtalakayan sa akin ang aking
pamilya tungkol sa aking problema.
G Ako’y nasisiyahan at ang aking
pamilya ay tinatanggap at
sinusuportahan ang aking mga nais
na gawin patungo sa mga bagong
landas para sa aking ikauunlad.
A’ Ako’y nasisiyahan sa paraang
ipinadadama ng aking pamilya ang
kanilang pagmamahal at
nauunawaan ang aking damdamin
katulad ng galit, lungkot at pag-ibig.
R Ako’y nasisiyahan na ang aking
pamilya at ako ay nagkakaroon ng
panahon sa isa’t isa.
Score Interpretations: 8 to 10 is Highly Functional; 4 to 7 is Moderately Dysfunctional; 0 to
3 is Severely Dysfunctional

Family APGAR 2 questionnaire

Ang pakikitungo naming sa
Ang mga miyembro
ang aking na (kasa- isa’t isa ay…
ng aking pamilya ay
(relasyon)… edad.. rian).. Tama Hindi
sina… Maayos
lang mabuti

29 | Page
 Family Map Instructions
1. Reconstruct genogram involving only the members of household.
2. Remove or minimize the “blood- and legal-relationship lines”.
3. Place psychodynamic relationship lines between index patient and household
members.
4. Add psychodynamic relationship lines between other members that affect
management.
5. Add Boundary lines running across each relationship lines
6. Add Brackets for Coalitions within the family
Psychodynamic relationship lines used in the Family Map Interpretati
ons
Distant or
dysfunction
al
relationshi
p
Normal
relations
Enmeshed
relations
Dominating
/
Controlling
relations
Conflictual
relations

Clear boundaries Diffuse Boundaries Coalitions

References:
1. Milagros Neri, Manuscript on FEU-NRMF Family Health Care Program
Procedures, [unknown year]
2. Lynn Bickley and Peter Szilagyi, Bates’ Guide to Physical Examination and
History Taking 11th edition, PA USA, 2013
3. Cohen et al, HEADSS assessment tool, 1991
4. Leopando et al, Textbook of Family Medicine volume 1, PH, 2014
5. US Preventive Services Task Force, The Guide to Clinical Preventive Services,
USA, 2014
6. DOH, Expanded Newborn Screening, PH, 2016
7. PPS, PIDSP and PFV, Childhood Immunization Schedule, PH, 2018
8. CDC, Adult Immunization Schedule by Vaccine and Age Group, 2018
9. CDC, Adult Immunization Schedule by Medical and Other Indications, 2018
-End-

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