Facility Code

Family Serial Number

Integrated Clinic Information System (iCLINICSYS)

PATIENT ENROLMENT and INDIVIDUAL TREATMENT RECORD

Instructions: For new patient only. Please print legibly and mark appropriate boxes with “X”.
Para sa mga bagong pasyente lamang. Mangyaring isulat nang malinaw at markahan ang naangkop na kahon ng “X”.
I. PATIENT INFORMATION (IMPORMASYON NG PASYENTE)
Last Name Suffix
(Apelyido) (e.g. Jr., Sr., II, III)
First Name Please write Maiden Name (for married women)
(Pangalan) Pangalan sa pagkadalaga (para sa mga babaeng may-asawa)
Middle Name
(Gitnang Pangalan)
Sex (Kasarian) Female (Babae) Male (Lalaki) Mother’s Name
(Pangalan ng Ina)
Birth Date (mm/dd/yyyy) / /
(Kapanganakan)
Birthplace
(Lugar ng Kapanganakan)
Blood Type Residential Address
(Tirahan)
Single Widow/er
(Walang Asawa) (Balo)
Married Separated
Civil Status (May Asawa) (Hiwalay)
(Katayuang Sibil)
Annulled Co-Habitation Contact Number
(Anulado) (Paninirahang
magkasama) DSWD NHTS? Yes No
Spouse’s Name Facility Household
(Asawa) No.
Educational Attainment No Formal Education Elementary 4Ps Member? Yes No
(Pang-edukasyong (Walang Pormal na (Elementarya)
katayuan) Household Number:
Edukasyon)
IP? Yes If Yes, what tribe?
High School Vocational PhilHealth Member? Yes No
(Hayskul) (Bokasyunal)
College Post Graduate Status Type: Member Dependent
(Kolehiyo)
Employment Status Student Unknown PhilHealth No.
(Katayuan sa (Estudyante) (Hindi malaman)
Pagtatrabaho)
Employed Retired FE – Private:
(May trabaho) (Retirado)
None/Unemployed (Walang Trabaho) FE – Government:
If Member, please
Father (Ama) Mother (Ina) indicate category IE:
Family Member
Son Daughter Others:
(Posisyon sa Pamilya)
(Anak na lalaki) (Anak na babae)
Others (Iba) Primary Care Benefit Yes No
(PCB) Member?
II. PATIENT’S CONSENT (PAHINTULOT NG PASYENTE)
IN ENGLISH SA FILIPINO

I have read and understood the Patient’s Information after I Aking nabasa at naintindihan ang Impormasyon ng Pasyente
have been made aware of its contents. During an matapos ako’y bigyang-kaalaman ng mga nilalaman nito. Sa isang pag-
informational conversation I was informed in a very uusap kasama ang kinatawan ng CHU/RHU, ako ay binigyang-paunawa
comprehensible way about the essence and importance of the nang mahusay tungkol sa kakanyahan at kahalagahan ng Integrated
Integrated Clinic Information System (iClinicSys) by the Clinic Information System (iClinicSys). Lahat ng aking mga katanungan
CHU/RHU representative. All my questions during the sa panahon ng pag- uusap ay nasagot ng sapat at ako ay binigyan ng sapat
conversation were answered sufficiently and I had been given na oras upang magpasya nito.
enough time to decide on this.

Furthermore, I permit the CHU/RHU to encode the Higit pa rito, pinapayagan ko ang CHU/RHU upang i-encode ang mga
information concerning my person and the collected data impormasyon patungkol sa akin at ang mga nakolektang impormasyon
regarding disease symptoms and consultations for said tungkol sa mga sintomas ng aking sakit at konsultasyong kaugnay
information system. dito para sa nasabing information system.
I wish to be informed about the medical results Nais kong malaman at maipaalam sa aking direktang kapamilya ang
concerning me personally or my direct descendants. Also, I can aking mga medikal na resulta. Gayundin, maari kong kanselahin ang aking
cancel my consent at the CHU/RHU any time without giving pahintulot sa CHU/RHU anumang oras na walang ibinibigay na dahilan at
reasons and without concerning any disadvantage for my medical walang kinalaman sa anumang kawalan para sa aking medikal na
treatment. pagpapagamot.

__________________________________________ __________________________________________
SIGNATURE OF PATIENT / DATE NAME OF CHU/RHU REPRESENTATIVE
PIRMA NG PASYENTE / PETSA KINATAWAN NG CHU / RHU

Clinic Information System | FORM 1

PRENATAL CARE POSTPARTUM CARE CHILD CARE
Date of
Gravida: LMP: delivery:
Birth Weight: Birth Length: Nut. Status:
Place of
Parity: EDC: Delivery:
Hepa B:
AOG at Mode of
Term: first Visit: Delivery:
BCG:
TT/TD? & Attendant
Preterm: Date Given: at Birth:
Pentavalent:
TT/TD? & Vitamin A
Livebirth: Date Given: given:
OPV:

Abortion: IPV:

PCV:

MCV:

Vit. A:
Part II. Please use this part for consultation of illness/well check-up (Prenatal Care, Postpartum Care, immunization, etc).

History of Present Treatment/Management

Date Physical Exam Assessment/Impression
Illness/Purpose of visit Plan/Health Services Provided
 Part II. Please use this part for consultation of illness/well check-up (Prenatal Care, Postpartum Care, immunization, etc).

History of Present Treatment/Management

Date Physical Exam Assessment/Impression
Illness/Purpose of visit Plan/Health Services Provided