LAST NAME: ________________________ FIRST NAME: ___________________________ MIDDLE NAME: ____________
BIRTHDAY: _________________AGE:_______ Philhealth No.: _________________________ BARANGAY: ___________________
KONSULTA FORM PAST MEDICAL HISTORY
Immunizations
FOR CHILDREN ____Allergy Specify Allergy: __________________________
____BCG ____Measles ____Asthma
____OPV1 ____Hep B1 ____Cancer Specify Organ with cancer: _________________
____OPV2 ____Hep B2 ____Cerebrovascular Disease
____OPV3 ____Hep B3 ____Coronary Artery Disease
____DPT1 ____Hep A ____Diabetes Mellitus
____DPT2 ____Varicella (chicken ____Emphysema
____Epilepsy/Seizure Disorder
pox)
____Hepatitis Specify Hepatitis type: _____________
____DPT3 ____None
____Hyperlipidemia
____Hypertension Highest blood pressure: ____________
FOR ADULT ____Peptic Ulcer
____HPV ____Pneumonia
____MMR ____Thyroid Disease
____None ____Pulmonary Specify Pulmonary Tuberculosis category: _____________________________
____Extrapulmonary Tuberculosis Specify Extrapulmonary Tuberculosis category:____________________
FOR PREGNANT WOMEN ____Urinary Tract Infection Others, please specify:_____________________________
____Tetanus Toxoid ____None
____None PAST SURGICAL HISTORY
OPERATION ____________________________________________________________________
FOR ELDERLY AND IMMUNOCOMPROMISED
____Pneumococcal Vaccine FAMIL Y HISTORY
____Flu Vaccine ____Allergy Specify Allergy: __________________________
____None ____Asthma
____Cancer Specify Organ with cancer: _________________
OTHERS, PLEASE SPECIFY ____Cerebrovascular Disease
____Coronary Artery Disease
PERSONAL/SOCIAL HISTORY ____Diabetes Mellitus
*Smoking ____Emphysema
____ Yes ____No ____Quit ____Epilepsy/Seizure Disorder
No. of packs/year? ____ ____Hepatitis Specify Hepatitis type: _____________
*Alcohol ____Hyperlipidemia
____Yes ____No ____Quit ____Hypertension Highest blood pressure: ____________
____Peptic Ulcer
No. of bottles/day? ____
____Pneumonia
*Illicit Drugs
____Thyroid Disease
____Yes ____No ____Pulmonary Tuberculosis Specify Pulmonary Tuberculosis category:
*Sexual History Screening _________________________________
Sexually Active ____Extrapulmonary Tuberculosis Specify Extrapulmonary Tuberculosis category:
____Yes ____No _________________________________
____Urinary Tract Infection Others, please specify:
FAMILY PLANNING ____None _________________________________
With access to family planning counselling
____Yes ____No
NCD HIGH RISK ASSESSMENT (for 20 yrs old and above)
High Fat/High Salt Food Intake
MENSTRUAL HISTORY Eat process/fast foods (e.g noodles, hamburgers, fries, fried chicken, skin, etc) and ihaw-ihaw (e.g isaw, adidas,
Menarche: ____ etc.) weekly ___Yes ___No
Onset of sexual intercourse: ____ yrs old DIETARY FIBER INTAKE
Menopause? NO____ if yes, what age? ____ 3 Servings vegetables daily: ___Yes ___No
Last Menstrual Period: (mm/dd/yyyy) ________ 2-3 servings of fruits daily: ___Yes ___No
Birth control method: _________________ PHYSICAL ACTIVITIES
Period duration: ____ days Does at least 2.5 hours a week of moderate-intensity physical activity:___Yes ___No
Interval cycle: ____ days PRESENCE OR ABSENCE OF DIABETES
No. of pads/day during menstruation: ______ 1. Was patient diagnosed as having diabetes? ___Yes ___No___Do not know
If yes, ___ with medication ____ without medication
OB-GYNE HISTORY ___Applicable ___Not And perform urine test ketones.
Applicable If no, do not proceed to question 2.
2. Does patient have the following symptoms?
PREGNANCY HISTORY
Polyphagia ___ Yes ____ No Polydipsia ___ Yes ____ No Polyuria ___ Yes ___ No
GP (TPAL): _________________________
If 2 or more of the above symptoms are present, perform blood glucose test
Type of delivery: ____________________
__________ Pregnancy-included hypertension Raised Blood Glucose: ___Yes ___No FBS/RBS: _______ mg/dL Date:_____
(pre-eclampsia) Raised Blood lipids: ___Yes ___No Total Cholesterol: _______ Date: ______
Presence of Urine Ketones: ___Yes ___No Urine Ketone: __________ Date: ______
PERTINENT PHYSICAL EXAMINATION FINDINGS Presence of Urine Protein ___Yes ___No
1st Blood Pressure: _____ mmHg
2nd Blood Pressure: _____ mmHg QUESTIONNAIRE TO DETERMINE PROBABLE ANGINA, HEART ATTACK, STROKE OR TRANSIENT ISCHEMIC
Heart Rate: ________ / min ATTACK
Respiratory Rate: _____/min
Temperature: ________ C ANGINA or HEART ATTACK: ____ Yes ____No
Visual Acuity: Left Eye: ____ 1. Have you had any pain or discomfort or any pressure or heaviness in your chest? ____ Yes ____No If no, go
Right Eye: ____ to Q8
Height: _____ (cm) ____ (in) Waist Circum:_____ 2. Do you get the pain in the center of the chest or left arm? ____ Yes ____No If no, go to Q8
Weight: _____ (kg) ____ (lb) Hip Circum:______ 3. Do you get it when you walk uphill or hurry? ____ Yes ____No
BMI: __________ 4. Do you slowdown if you get the pain while walking? ____ Yes ____No
Blood Type: ________ 5. Does the pain go away if you stand still or take a tablet under the tongue? ___ Yes ___No
6. Does the pain go away in less than 10 minutes? ____ Yes ____No
Pediatric Client Aged 0-24 months 7. Have you ever had a severe chest pain across the front of your chest lasting for half an hour or more? ____
Length: _________ (cm) Yes ____No
Head Circumference: _____ (cm) If the answer to question 3/4/5/6/7 is YES, patient have angina or heart attack and needs to see the doctor
Skinfold Thickness: _______
Waist: _________ (cm) STROKE or TIA: ____ Yes ____No
Hip: _________ (cm) 8. Have you ever had any of the following: difficulty in talking, weakness of arm and/ or leg on one side of the
Limbs: _________ (cm) body or numbness on one side of the body? ____ Yes ____No
MUAC: _________ (cm) If the answer to question 8 is YES, the patient may have had a TIA or stroke and needs to see the doctor.
Pediatric Client Aged 0-60 months RISK LEVEL: ____<5%% _____5% to <10% ____ 10% to<20% ____ 20% to <30%___≥30%
Z-Score: __________
Name of Interviewer: ___________________________________ Date: _______________________
LAST NAME: ________________________ FIRST NAME: ___________________________ MIDDLE NAME: ________________
CONSULTATION FORM
CHIEF COMPLAINT PERTINENT FINDINGS PER SYSTEM
___Abdominal Cramp/Pain ___Hematemesis
___Altered mental sensorium ___Hematuria A. HEENT
___Anorexia ___Hemoptysis ____Essentially normal ____Abnormal pupillary reactions ____Cervical
lymphadenopathy ____Dry mucos membrane ____Icteric ____Pale conjunctivae
___Bleeding Gums ___Irritability
sclerae ____Others
___Blurring of Vision ___Jaundice
___Body Weakness ___Lower B. CHEST/BREAST/LUNGS
extremity edema ____Essentially normal ____Asymmetrical chest expansion ____Decreased breath
___Chest pain/discomfort ___Myalgia sounds ____Enlarge Axillary Lymph nodes ____Wheezes ____Lumps over breast
___Constipation ___Orthopnea (s) ____Others
___Cough ___Pain
___Diarrhea ___Palpitations C. HEART
___Dizziness ___Seizures ____Essentially normal ____Displaced apex beat ____Heaves/thrills ____
___Dysphagia ___Skin rashes Irregular rhythm ____Muffled heart sounds ____murmurs ____Pericardial bulge
____Others
___Dysuria ___Stool,
bloody,black tarry,
D. ABDOMEN
mucoid ____Essentially normal ____Abdominal rigidity ____Abdominal tenderness
___Epistaxis ___Sweating ____Hyperactive bowel sounds ____Palpable mass ____Tympanic /dull abdomen
___Fever ___Urgency ____Uterine contraction
___Frequency of urination ___Vomiting/
nausea E. GENITOURINARY
___Headache ___Weight loss ____Essentially normal ____Blood stained in exam finger ____Cervical dilatation
____Presence of abnormal discharge ____Others
HISTORY OF ILLNESS F. DIGITAL RECTAL EXAM
____Essentially normal ____ Enlarge Prostate ____Mass ____Hemorrhoids
____Pus ____ Not applicable ____Others
G. SKIN/EXTREMITIES
____Essentially normal ____Abnormal gait ____Abnormal position sense
____Abnormal sensation ____Abnormal reflex ____Poor/altered memory
____Poor muscle tone/strength
PLAN/MANAGEMENT
DIAGNOSIS:
A. LABORATORY/IMAGING
B. MANAGEMENT (check if done) Not Applicable: ___Yes ___No
___Breastfeeding Program Education
___Counselling for Smoking Cessation
___Counselling for Lifestyle Modification
___Oral Check-up and Prophylaxis
Others: ____________________________
C. THERAPEUTICS (*not dispensed)
D. ADVISE
