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Initial and Annual Health Record

This document is a health record form for a child in the Philippines that collects information about: 1) The child's maternal health history and any illnesses during pregnancy. 2) Details of the child's birth such as delivery type and location as well as any complications. 3) The child's immunization history and dates for vaccines including DPT, polio, BCG, measles, tetanus and hepatitis. 4) Information on the child's current health status, any disabilities, previous illnesses, deworming treatments, allergies and results of a physical examination.

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mariegold mortola fabela
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5K views2 pages

Initial and Annual Health Record

This document is a health record form for a child in the Philippines that collects information about: 1) The child's maternal health history and any illnesses during pregnancy. 2) Details of the child's birth such as delivery type and location as well as any complications. 3) The child's immunization history and dates for vaccines including DPT, polio, BCG, measles, tetanus and hepatitis. 4) Information on the child's current health status, any disabilities, previous illnesses, deworming treatments, allergies and results of a physical examination.

Uploaded by

mariegold mortola fabela
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Republic of the Phiippines

Province of Misamis Oriental

District : _______________________________________________________________
Child Development Center : _______________________________________________________________
Child Development Worker : _______________________________________________________________
Name of Child : ___________________________ Birth Date: _________ Age: ____ Sex: ____

INITIAL AND ANNUAL HEALTH RECORD


(For use of the Physician)

1. Maternal History : Please check illness/es during pregnancy.


__________ Goiter __________ German Measles
__________ Diabetes __________ Hepatitis
__________ Tuberculosis __________ Sexually Transmitted Disease
__________ Heart Disease __________ Others (please specify)
2. Brief History
A. Type of Delivery
_____ Normal Spontaneous Delivery
_____ Caesarian Section
_____ Forceps
B. Place of Delivery
__________ Hospital
__________ Home
__________ Other (please specify)
C. State Complication, if any: _______________________________________________________
____________________________________________________________________________
D. Allergies, if any: _______________________________________________________________
____________________________________________________________________________
3. Immunization Dates Given
 DPT _______________ _______________
 POLIO _______________ _______________
 BCG _______________ _______________
 MEASLES _______________ _______________
 TETANUS _______________ _______________
 HEPATITIS _______________ _______________
4. Deworming Date of Last Deworming
_____ Yes _______________ _______________
_____ No _______________ _______________
5. Disability/Impairments: Please check if any.
_____________ Congenital Deformities ____________ Speech Defect
_____________ Deafness ____________ Emotional Disturbances
____________ Other (please specify)
6. Previous Illness Date
__________________________________________________ _______________
__________________________________________________ _______________

7. Current Health Status


__________________________________________________________________________________
__________________________________________________________________________________
8. Pertinent Physical Examination
HEENT _______________ CHEST/LUNGS _______________
ABDOMEN _______________ GUT _______________
MASCULAR _______________ NEURO _______________
9. Children with disability (Please encircle: H.L. / S.L. / M.L. / Orthopedics )
10. Remarks: __________________________________________________________________________
__________________________________________________________________________________

________________________________
SIGNATURE ABOVE PRINTED NAME
Date: ___________________________

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