PWHS FORM 5.

KONSULTA HEALTH ASSESSMENT TOOL v3

NCD HIGH-RISK ASSESSMENT

PERSONNEL
AUTHORIZED
GENERAL DATA AND KONSULTA REGISTRATION
(FOR 20 YRS OLD AND ABOVE)
FULL NAME LAST FIRST MIDDLE PERTINENT FINDINGS PER SYSTEM 1. Eats processed food (ex. Instant Noodles, Burgers,
PHYSICAL EXAMINATION Fries, Fried Chicken Skin, etc) and ihaw-ihaw Weekly?
AGE SEX ¨ F ¨M BIRTHDATE (MM/DD/YYYY) / / o Yes o No
ADDRESS PUROK BARANGAY MUNICIPALITY GENERAL SURVEY 2. Eats 3 servings of Vegetable Daily?
o Awake and alert o Altered sensorium o Yes o No
CONTACT # E-MAIL 3. Does at least 2.5 hours of moderate-intensity physical

DATE OF APPOINTMENT:_________________
_____________________________________
A. HEENT E.. Genitourinary activity every week?
PHILHEALTH PIN
o Yes o No

AUTHORIZATION TRANSACTION CODE

¨ Essentially Normal
MEMBER TYPE ¨ MEMBER ¨ DEPENDENT Specify: ¨ Essentially Normal ¨ Blood Stained in Internal 4. Was patient diagnosed as having Diabetes?
KONSULTA REGISTRATION REGISTRATION DATE (MM/DD/YYYY) / / . KPP SIGN ¨ Abnormal Papillary Reaction Examination o Yes o No ¨ Do not know
¨ Cervical Lymphadenopathy ¨ Cervical Dilation If YES: o With Medication o Without
CHOICE 1: ¨ ¨ Dry Mucus Membrane ¨ Presence of Abnormal Medication
PREFERRED FACILITY ¨ Icteric Sclerae Discharge 5. Does the patient have any of the following symptoms?
AND ADDRESS CHOICE 2: ¨ ¨ Pale Conjunctiva ¨ Others : __________ o Polyphagia o Polydipsia o Polyuria
CHOICE 3: ¨ ¨ Sunken Eyeball
¨ Sunken Fontanelle F. Digital Rectal Examination FBS/RBS: ________ Date taken : ________
AUTHORIZATION TRANSACTION ¨ Others : __________ ¨ Essentially Normal Total Cholesterol: ________ Date taken : ________
¨ AT CODE: DATE OF APPOINTMENT / / If no ATC, ¨ FACE CAPTURE ¨ Enlarge Prostate Urine Ketone: ________ Date taken : ________
B. Chest/Breast/ Lungs ¨ Mass Urine Protein: ________ Date taken : ________
¨ Hemorrhoids
¨ Essentially Normal ¨ Pus Angina or Heart Attack o Yes o No
MEMBER / GUARDIAN’S SIGNATURE ¨ Asymmetrical Chest ¨ Not Applicable 1. Have had any pain/discomfort pressure/ heaviness in
Expansion ¨ Others : __________ your chest? Nakararamdam ka ba ng pananakit o bigat
HEALTH ASSESSMENT TOOL ¨ Decreased Breath Sounds sa iyong dibdib?
¨ Wheezes G. Skin/Extremities o Yes o No if no, go to question 8
PAST MEDICAL HISTORY IMMUNIZATION ¨ Crackles/Rales ¨ Essentially Normal 2. Do you get the pain in the center/left chest or left arm?
¨ Allergy (Specify: ______________________) Children ¨ Retractions ¨ Clubbing Ang sakit ba ay nasa gitna ng dibdib, sa kaliwang
¨ Asthma ¨ BCG ¨ OPV1 ¨ OPV2 ¨ OPV3 ¨ Lumps Over Breast ¨ Cold Clammy bahagi ng dibdib o sa kaliwang braso?
¨ Cancer (Specify: ______________________) ¨ DPT1 ¨ DPT2 ¨ DPT3 ¨ Measles ¨ Others : __________ ¨ Cyanosis/Mottled Skin o Yes o No if no, go to question 8
¨ Cerebrovascular Disease ¨ Hepa1 ¨ Hepa2 ¨ Hepa3 ¨ Varicella ¨ Edema/Swelling 3. Do you get it when you walk uphill or hurry?
¨ Coronary Artery Disease Adult C. Heart ¨ Decreased Mobility Nararamdaman mo ba ito kung ikaw ay nagmamadali o
¨ Pale Nailbeds naglalakad nang mabilis o paahon?

AUTHORIZED
PERSONNEL
¨ Diabetes Mellitus ¨ HPV ¨ MMR ¨ None
¨ Emphysema Elderly and Immunocompromised ¨ Essentially Normal ¨ Weak Pulses o Yes o No
¨ Epilepsy / Seizure Disorder ¨ Pneumococcal Vaccine ¨ Displaced Apex Beat ¨ Others : __________ 4. Do you slowdown if you get the pain while walking?
¨ Hepatitis (Specify: ____________________) ¨ Flu Vaccine ¨ Heaves/Trills Tumitigil ka ba sa paglalakad kapag sumasakit ang
¨ Hyperlipidemia Others: __________________________________ ¨ Irregular Rhythm H. Neurological Examination iyong dibfib?
¨ Hypertension (Highest BP: _____________mmHg) ¨ Muffled Heart Sounds ¨ Essentially Normal o Yes o No
¨ Murmurs ¨ Abnormal Gait 5.Does the pain go away if you stand still or if you get

PROVIDER: ____________________________________________________
KPP ADDRESS: ________________________________________________
¨ Peptic Ulcer FAMILY PLANNING

FULL NAME: __________________________________ PIN. ____________

¨ Pneumonia ¨ With access to family planning counseling ¨ Pericardial Bulge ¨ Abnormal Position Sense medication? Nawawala ba ang sakit sa dibdib kapag
¨ Thyroid Disease Provider: ____________________________ ¨ Others : __________ ¨ Abnormal Sensation ikaw ay tumitigil o umiinom ng gamot sa ilalim ng dila?
¨ PTB (Specify Extra PTB: _____________________) Birth Control Method used: ____________________ ¨ Abnormal Reflex/es o Yes o No

PHILHEALTH KONSULTA REGISTRATION CONFIRMATION SLIP

¨ Urinary Tract Infection D. Abdomen ¨ Poor/Altered Memory 6.Does the pain go away in <10 minutes? Nawawala ba
¨ Mental Illnesses MENSTRUAL HISTORY ¨ Poor Muscle ang sakit sa loob ng 10 minuto?
¨ Others Menarche: _________ yrs old ¨ Essentially Normal Tone/Strength o Yes o No
Past Surgery/ies Done: ______________________ Onset of sexual intercourse __________ yrs old ¨ Abdominal Rigidity ¨ Poor Coordination 7. Have you ever had severe chest pain across the front of
Date Done: ______________________ Last Menstrual Period: _____/_____/________ ¨ Abdominal Tenderness ¨ Others : __________ your chest lasting for half an hour or more?
FAMILY HISTORY Period Duration: __________days ¨ Hyperactive Bowel Sounds Nakaramdam ka na ba ng pananakit ng dibidib na
¨ Allergy (Specify: ______________________) No. of pads/day: ________________ ¨ Palpable Mass/es tumatagal ng kalahating oras o higit pa?
¨ Asthma Interval cycle: __________days ¨ Tympanitic/Dull Abdomen o Yes o No
¨ Cancer (Specify: ______________________) Menopause: ¨ Yes ¨ No ¨ Uterine Contraction * If YES to number 3, 4, 5, 6 and 7, the patient have ANGINA/ HEART
¨ Cerebrovascular Disease ¨ Others : __________ ATTACK, must see a doctor.
¨ Coronary Artery Disease PREGNANCY HISTORY
¨ Diabetes Mellitus (if yes, perform FBS:__________) G___ P___ (T____ P____ A____ L____) Stroke and TIA o Yes o No
¨ Emphysema Type of Delivery: __________________________ 8.Have you ever had difficulty in talking, weakness of arms
¨ Epilepsy / Seizure Disorder Pregnancy Induced Hypertension: ¨ Yes ¨ No or legs on the one side of the body? Nakaramdan ka
FIRST PATIENT ENCOUNTER ASSESSMENT:
¨ Hepatitis (Specify: ____________________) na ba ng ano man sa mga sumusunod: pagkautal,
o GENERALLY WELL (fill out and sign eKAS) panghihina ng braso o binti, o pamamanhid ng
¨ Hyperlipidemia PERTINENT PHYSICAL EXAMINATION FINDINGS
¨ Hypertension (Highest BP: _____________mmHg) Height: ________cm BP: _______mm/Hg o FOR PRIMARY CARE CONSULTATION (fill out KONSULTA Referral Slip) kalahati ng katawan?
¨ Peptic Ulcer Weight: ________kg HR: _______ bpm o FOR DIAGNOSTIC EXAMINATION (fill out Diagnostic Request Form) o Yes o No
¨ Pneumonia Temp : ________OC RR: ________ cpm * If YES to number 8, you may have TIA/Stroke, must seek a doctor.
¨ Thyroid Disease Blood Type: ¨ A+ ¨ B+ ¨ AB+ ¨ O+
¨ PTB (Specify Extra PTB: _____________________) ¨ A- ¨ B- ¨ AB- ¨ O- RISK LEVEL
¨ Urinary Tract Infection Visual Acuity: Right Eye:_____ Left Eye: ______ o <10% o 10% to <20% o 20% to <30%
¨ Mental Illnesses o 30% to <40% o >40%
¨ Other__________________________________ PEDIA CLIENT AGED 0-24 MOS FIRST PATIENT ENCOUNTER CONSULTATION ENCODING
PERSONAL/ SOCIAL HISTORY Body Length: ________ cm
Smoking ¨Yes ¨No ¨Quit Head Circumference: ________ cm
No. of pack-years: ____________________ Chest Circumference: ________ cm Province of Quezon SIGNATURE
Alcohol ¨Yes ¨No ¨Quit Abdominal Circumference: ________ cm PROVINCE-WIDE
No. of servings/day: ____________________ Hip Circumference: ________ cm HEALTH SYSTEM NAME
PWHS FORM 5. KONSULTA POSITION
Illicit Drugs ¨Yes ¨No ¨Quit Mid-Upper Arm Circumference: ________ cm HEALTH ASSESSMENT TOOL
Sexually Active ¨Yes ¨No ¨Quit Limbs Circumference: ________ cm version 3 DATE
 KONSULTA AVAILMENT SLIP (KAS)
KONSULTA PACKAGE PROVIDER : LINGAP SA MAMAMAYAN,
___________________________________________________
To be filled out by the facility (pupunan ng pasilidad)
✓ PERFORMED DATE PERFORMED BY
LIBRENG GAMUTAN
(nagawa) PERFOMED (Ginawa ni) CONSULTATION 1 CONSULTATION 2
KONSULTA SERVICES 𝓧 NOT (Petsa kung Initial/Signature of
¨ PRIMARY CARE/FAMILY MED ¨ IM ¨ SURG ¨ PRIMARY CARE/FAMILY MED ¨ IM ¨ SURG
PERFORMED kelan healthcare
¨ PEDIA ¨ OB-GYN ¨ ORL/ENT ¨ OPHTHA ¨ PEDIA ¨ OB-GYN ¨ ORL/ENT ¨ OPHTHA
(hindi nagawa) ginawa) provider/technician
¨ DERMA ¨ _____________________________ ¨ DERMA ¨ _____________________________
History and Physical Examination CHIEF
NCD Risk Assessment COMPLAINT
Medical Consultation/ Check-up
Diagnostic Examination
Complete blood count with platelet count
PERTINENT
Lipid Profile
FINDINGS
Fasting Blood Sugar
Oral Glucose Tolerance Test
HBA1c
Creatinine
Chest X-ray
Sputum Microscopy
12-L Electrocardiogram ASSESSMENT/
Urinalysis DIAGNOSIS
Pap smear
Fecalysis
Fecal Occult Blood Test
Dispensing of NCD Meds
Dispensing of Antibiotic

To be filled out by patient (pupunan ng pasyente)

Have you received the abovementioned essential services?
¨ YES / OO ¨ NO / HINDI
Natanggap mo ba ang mga essential services na nabanggit?
PLAN
How satisfied are you with the services provided?
Gaano ka nasiyahan sa natanggap mong serbisyo? ¨ 😊 ¨😐 ¨☹
For your comment, suggestion or complaint?
Para sa iyong komento, mungkahi o reklamo

Under the penalty of law, I attest that the information I provided in this slip are true and FOR
accurate. REFERRAL
(Sa ilalim ng batas, pinatutunayan ko na ang impormasyong ibinigay ko ay totoo at tama. TO:

PHYSICIAN
SIGNATURE
___________________________________ Next Consultation Date: _____________ NAME
Signature over printed name of patient Petsa ng Susunod na Konsultasyon
Lagda sa nakalimbag na pangalan ng pasyente