OUR LADY OF MT.

CARMEL MEDICAL CENTER

PHILHEALTH ACCREDITED

PHILHEALTH EPCB HEALTH SCREENING & ASSESSMENT FORM

LAST NAME: FIRST NAME: MIDDLE NAME:

ADDRESS : CONTACT #:

PLACE OF BIRTH :

(PROVINCE) (CITY/MUNICIPALITY)

DATE OF BIRTH: SEX: CIVIL STATUS:

PAST MEDICAL HISTORY: PAST SURGICAL HISTORY:

FAMILY HISTORY: OB- GYNE HISTORY:

IMMUNIZATIONS: PERSONAL/SOCIAL HISTORY

SMOKING: No. of pack/year?
   ⃝ YES             ⃝ NO                 ⃝ QUIT
 ALCOHOL: No. of bottles/day?
   ⃝ YES             ⃝ NO                 ⃝ QUIT

ILLICIT DRUGS:
   ⃝ YES             ⃝ NO          

OUR LADY OF MT. CARMEL MEDICAL CENTER

PHILHEALTH ACCREDITED

PHYSICAL EXAMINATION:

BP:_____________ HR: _______________ RR: _________ TEMP: _______________ HT: _________ WT: _____

GENERAL SURVEY:

HEENT:

HEART:

CHEST/LUNGS:

ABDOMEN:

EXTREMITIES:

NEUROLOGICAL:

CLINICAL IMPRESSION:

PLAN MANAGEMENT:
PHYSICIAN'S NAME/SIGNATURE
V/A: _________
 OUR LADY OF MT. CARMEL MEDICAL CENTER
PHILHEALTH ACCREDITED

PHILHEALTH EPCB HEALTH SCREENING & ASSESSMENT FORM

LAST NAME: _________________________ FIRST NAME: __________________________ MIDDLE NAME: _____________

ADDRESS : ______________________________ SEX: ____________ CIVIL STATUS: _______________________

DATE OF BIRTH: _______________________ PLACE OF BIRTH : ___________________________________________

*PAST MEDICAL HISTORY

Allergy Specify Allergy: ____________________________
Asthma
Cancer Specify organ with cancer: ______________________
Cerebrovascular Disease
Coronary Artery Disease
Diabetes Mellitus
Emphysema Highest blood pressure: ______________________
Epilepsy/Seizure Disorder
Hepatitis Specify hepatitis type: ________________________
Hyperlipidemia
Hypertension
Peptic Ulcer Specify Extrapulmonary Tuberculosis category: ____________________
Pneumonia
Thyroid Disease
Pulmonary Tuberculosis
Extrapulmonary Tuberculosis Specify Pulmonary Tuberculosis category: _______________________
Urinary Tract Infection
Mental Illness
Others
None Others, please specify: ______________________________________

*FAMILY HISTORY
Allergy Specify Allergy: ____________________________
Asthma
Cancer Specify organ with cancer: ______________________
Cerebrovascular Disease
Coronary Artery Disease
Diabetes Mellitus
Emphysema Highest blood pressure: ______________________
Epilepsy/Seizure Disorder
Hepatitis Specify hepatitis type: ________________________
Hyperlipidemia
Hypertension
Peptic Ulcer
Pneumonia
Thyroid Disease
Pulmonary Tuberculosis
Extrapulmonary Tuberculosis Specify Pulmonary Tuberculosis category: _______________________
Urinary Tract Infection
Mental Illness
Others
NONE Others, please specify: ______________________________________

PERSONAL/SOCIAL HISTORY OB- GYNE HISTORY:

SMOKING:
   ⃝ YES             ⃝ NO                 ⃝ QUIT
If Yes: No. of pack/year? _____________
ALCOHOL:
   ⃝ YES             ⃝ NO                 ⃝ QUIT IMMUNIZATIONS:
If Yes: No. of bottle/day? _____________
ILLICIT DRUGS:
   ⃝ YES             ⃝ NO                 ⃝ QUIT
 OUR LADY OF MT. CARMEL MEDICAL CENTER
PHILHEALTH ACCREDITED

PERTINENT PHYSICAL EXAMINATION FINDINGS

BP:_____________ HR: _____ RR: _______ TEMP: ___________ LMP (FEMALE ONLY) :_____________

HEIGHT: ______________________ WEIGHT: ________________ VISUAL ACQUITY: ___________________

General Survey: Awake and alert Altered Sensorium

*A. HEENT *B. Chest/Breast/Lungs
Essentially Normal Essentially normal
Abnormal pupillary reaction Asymmetrical chest expansion
Cervical lympadenopathy Decreased breath sounds
Dry mucous membrane Enlarge Axillary Lymph Nodes
Dry mucous membrane Wheezes
Icteric sclerae Lumps over breast(s)
Pale conjunctivae Crackles/rales
Sunken eyeballs Retractions
Sunken fontanelle OTHERS: _________________
OTHERS: _________________

*C. Heart *D. Abdomen

Essentially normal Essentially normal
Displaced apex beat Abdominal rigidity
Heaves/trills Abdominal tenderness
Irregular rhythm Hyperactive bowel sounds
Muffled heart sounds Palpable mass(es)
Murmurs Tympanitic/dull abdomen
Pericardial bulge Uterine contraction
OTHERS: _________________ OTHERS: _________________

*E. Genitourinary *F. Digital Rectal Examination

Essentially normal Essentially normal
Blood stained in exam finger Enlarge Prospate
Cervical dilatation Mass
Presence of abnormal discharge Hemorrhoids
OTHERS: _________________ Pus
Not Applicable
OTHERS: _________________

*G. Skin/Extremities *H. Neurological Examination

Essentially normal Essentially normal
Clubbing Abnormal gait
Cold clammy Abnormal position sense
Cyanosis/mottled skin Abnormal sensation
Edema/swelling Abnormal reflex(es)
Decreased mobility Poor/altered memory
Pale nailbeds Poor muscle tone/strength
Poor skin turgor Poor coordination
Rashes/Petechiae OTHERS: _________________
Weak pulses
OTHERS: _________________

RECOMMENDATIONS:
__________________________________________
PHYSICIAN'S NAME/SIGNATURE
 OUR LADY OF MT. CARMEL MEDICAL CENTER OUR LADY OF MT. CARMEL MEDICAL CENTER
PHILHEALTH ACCREDITED PHILHEALTH ACCREDITED

PHILHEALTH EPCB LABORATORY AND DIAGNOSTIC EXAM REQUEST PHILHEALTH EPCB LABORATORY AND DIAGNOSTIC EXAM REQUEST

Name of patient: ____________________________ Age/Sex: _____________ Name of patient: ____________________________ Age/Sex: _____________
Lifestage group Essential Services Lifestage group Essential Services
A. 0-12 months: CBC A. 0-12 months: CBC
B. >1-4 years: CBC B. >1-4 years: CBC
Fecalysis Fecalysis
Urinalysis Urinalysis
C. 5-9 years old: CBC C. 5-9 years old: CBC
Fecalysis Fecalysis
Urinalysis Urinalysis
D. 10-19 years old: Paps smear (as applicable) D. 10-19 years old: Paps smear (as applicable)
CBC CBC
Fecalysis Fecalysis
Urinalysis Urinalysis
Chest X-ray Chest X-ray
E. 20-60 years old: Paps smear (as applicable) E. 20-60 years old: Paps smear (as applicable)
(female) Chest X-ray (female) Chest X-ray
Lipid Profile Lipid Profile
FBS (for follow up) FBS (for follow up)
Oral Glucose Tolerance Test ( for initial ) Oral Glucose Tolerance Test ( for initial )
Sputum microscopy (as applicable e.g. TB suspected) Sputum microscopy (as applicable e.g. TB suspected)
ECG (for 30 y/o and up) ECG (for 30 y/o and up)
F. 20-60 years old: Chest X-ray F. 20-60 years old: Chest X-ray
(male) Lipid Profile (male) Lipid Profile
FBS (for follow up) FBS (for follow up)
Oral Glucose Tolerance Test ( for initial ) Oral Glucose Tolerance Test ( for initial )
Sputum microscopy (as applicable e.g. TB suspected) Sputum microscopy (as applicable e.g. TB suspected)
ECG (for 30 y/o and up) ECG (for 30 y/o and up)
G. > 60 years old: Paps smear (for female) G. > 60 years old: Paps smear (for female)
Chest X-ray Chest X-ray
Lipid Profile Lipid Profile
FBS (for follow up) FBS (for follow up)
Oral Glucose Tolerance Test ( for initial ) Oral Glucose Tolerance Test ( for initial )
Sputum microscopy (as applicable e.g. TB suspected) Sputum microscopy (as applicable e.g. TB suspected)
ECG ECG
PHILHEALTH EPCB HEALTH SCREENING & ASSESSMENT FORM

PHILHEALTH EPCB HEALTH

SCREENING & ASSESSMENT FORM

PHILHEALTH EPCB LABORATORY AND DIAGNOSTIC EXAM REQUEST

PHILHEALTH EPCB LABORATORY AND

DIAGNOSTIC EXAM REQUEST