ICNCDRS Coronary Artery Disease Registry Form

Date as of July 01, 2013
REC-005-Jul2013-Rev0
DEPARTMENT OF HEALTH
Integrated Chronic Non-Communicable Disease Registry System
1 National Registry No.
Coronary Artery Disease Registry Form

Note: Please put N/A for Not Applicable fields. Kindly refer to the instruction on how to fill up the form at the back.
GENERAL DATA
2 Name of Reporting Health Facility
3 Hospital Patient ID No.
4 Hospital Registry No.
7 Name of Patient*
5 Hospital Case No.
8 Sex*
Female
Male
9 Civil Status
Single
____________________ __________________ ____________________
Widow/er
Last Name
First Name
Middle Name
Co-Habitation
10 Mothers Maiden Name ________________________ ______________________ _______________________
Last Name
First Name
Region
Province
City/Municipality
Barangay
13 Birth Date *
Region
Province
City/Municipality
14 If Date of Birth is not available
15 Place of Birth (Province,City/Municipality)
____/____/____
____Yrs ____ Mos ____ Days
mm dd yyyy
20 Highest Educational Attainment
21 Occupation
24 Contact Person (in case of emergency)
Barangay
22 Company
_________________, ___________________, ____________

Last Name
First Name
Region
Province
PATIENT HISTORY
25 Smoking
Less than/Equal to 1 pack
consumed per day
More than 1 pack consumed/day
Age started Smoking: ________
No. of Years Smoking: ________
City/Municipality
Barangay
26 Physical Activity
a.Type:___________________________________
__________________________________
c.Frequency:______________________________
________________________________
Fish, Meat, Poultry, Egg

Specify _________________________
FrequencyDaily Weekly Monthly Yearly Quarterly
Rice, Grains, Bread, Cereals, RootCrops

Specify _________________________
Fruits/Vegetables
Specify _________________________
Fats, Oils
Specify _________________________
Sugar, Sweet
Specify _________________________
Milk and Milk Products

Specify _________________________
12c Email Address
__________
Zip Code
16 Religion
18 Race
17 Nationality
19 Ethnicity
23 PhilHealth #
23a Common Reference #
24b Landline #
24d Email Address
24c Mobile #
Zip Code
b. Minutes per Exercise Activity:

__________________________________
__________________________________
25a Second Hand Smoke (SHS)

With Exposure to SHS
Number of Years: ______
28 Usual/ Typical Diet Intake
12a Mobile #
Middle Name
24a Address
_________________ _________ _________________ _________________ _______________ __________
Number & Street Name
12 Landline #
__________
Zip Code
11a Temporary Address

____________________ _________ _____________________ _____________________ _________________
Married
Separated
Annulled Divorced
Middle Name
11 Permanent Address
____________________ _________ _____________________ _____________________ _________________
6 Type of Patient
OPD In Patient
29 Drinking of Alcoholic Beverage

a. Type: __________________________
b. Amount: _______________________
c. Unit of Measure: Bottle Glass Shot
d. Frequency: Daily Weekly Monthly
Yearly Quarterly
Age started drinking alcohol: _______

No. of Years drinking alcohol: ______
27 Previous Diagnosis
Chronic Coronary Heart Disease/ Ischemic
Heart Disease
Heart Attack/ Myocardial Infarction
High Blood Pressure/ Hypertension
Heart Rhythm Disorder
Rheumatic Heart Disease
Congenital Heart Disease
Cardiomyopathy
Chronic Obstructive Pulmonary Disease
Others, specify ___________ None
31a Height in Meter
31b Weight in Kilograms

31c Body Mass Index
31d Classification (BMI)
31e Waist circumference in centimeters
30 Family History of CAD

Family Member
___________________
___________________
___________________
31f Classification (WC)

Type
______________
______________
______________
Others
Specify _________________________
31g Blood Pressure (Systolic/Diastolic)

32 Cholesterol Level mg/dL (milligrams per deciliter)
159 or lower
160-199
200-239
240-279
280 or Higher
Unaware
Coronary Artery Disease DATA

33Referred From
36 Date of Consultation/
Admission
____/____/_____
mm dd yyyy
34 Name of Referring Health Facility/Doctor/Health Care Professional
35 Reason for Referral
37 Chief Complaint:
38 Date of Diagnosis
____/____/_____
mm dd yyyy
DEPARTMENT OF HEALTH
Integrated Chronic Non-Communicable Disease Registry System
Date as of July 01, 2013

REC-005-Jul2013-Rev0
39 Signs and Symptoms

Nausea
Palpitations
Cold Sweating (Diaphoresis)
Backache
Vomiting
Orthopnea
Edema
Weakness
Cough
Shortness of breath
Abdominal Pain
Fainting
Jaw Pain
Chest pain (Angina)
Feeling of indigestion
Cyanosis
Dizziness
Left Arm Numbness
Easy Fatigability
None
Anxiety
Pallor
Numbness
Others, specify __________________
40 Basis of Diagnosis
Physical Examination
Echocardiography
CT Angiography
Treadmill Stress Test or Exercise Stress Test
Coronary Angiogram
Chest CT Scan
Radionuclide Thallium Scan/Stress Test
Electrocardiogram (ECG)
Biochemical Cardiac Markers (CK-MB,Troponin)
Chest X-Ray
Holter Monitoring
Others, specify ______________________
41 Final Diagnosis
42 Final Diagnosis: ICD-1O Code
43 Treatment Given
44 Patient Status Recovered Improved Unimproved Died
45 If died, underlying Cause of Death
46 If died, underlying Cause of Death: ICD-1O Code
47 Date of Death
48 Place of Death
____/____/_____
(mm/ dd/ yyyy)
50 If Transferred, Name of Health Facility
49 Disposition Admitted
Discharged
Transferred
51 Reason for Referral
52 Consultant in-charge _________________, ___________________, ____________

Last Name
First Name
Middle Name
____________________
Region
Province
City/Municipality
Last Name
First Name
Region
Province
Barangay
Zip Code
____________________
Middle Name
City/Municipality
52d Email Address
52c Mobile #
53b Landline #
53d Email Address
53c Mobile #
54 Date Completed
____/____/___
Department
53a Address
_________________ _________ _________________ _______________ ___________ _______
52b Landline #
Department
52a Address _________________ _________ _________________ _________________ ____________

_______
53 Completed By _________________, ___________________, __________________
Discharge Against Medical Advice

Treated and Sent Home
Absconded
Barangay
Zip Code
mm dd
yyyy

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Date as of July 01, 2013

1 National Registry No.

Coronary Artery Disease Registry Form

3 Hospital Patient ID No.

4 Hospital Registry No.

5 Hospital Case No.

14 If Date of Birth is not available

15 Place of Birth (Province,City/Municipality)

_________________, ___________________, ____________

Fish, Meat, Poultry, Egg

Rice, Grains, Bread, Cereals, RootCrops

Milk and Milk Products

12c Email Address

23a Common Reference #

24d Email Address

b. Minutes per Exercise Activity:

25a Second Hand Smoke (SHS)

11a Temporary Address

29 Drinking of Alcoholic Beverage

Age started drinking alcohol: _______

31b Weight in Kilograms

30 Family History of CAD

31f Classification (WC)

FrequencyDaily Weekly Monthly Yearly Quarterly

31g Blood Pressure (Systolic/Diastolic)

FrequencyDaily Weekly Monthly Yearly Quarterly

Coronary Artery Disease DATA

34 Name of Referring Health Facility/Doctor/Health Care Professional

35 Reason for Referral

Date as of July 01, 2013

39 Signs and Symptoms

42 Final Diagnosis: ICD-1O Code

46 If died, underlying Cause of Death: ICD-1O Code

52 Consultant in-charge _________________, ___________________, ____________

Number & Street Name

52d Email Address

53d Email Address

52a Address _________________ _________ _________________ _________________ ____________

Discharge Against Medical Advice

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_______, _, ____

52 Consultant in-charge _______, _, ____

52a Address _____________ _ _____ _ ____