Secretary
Gender Birthday
First Name
Complain
Name Middle Initial Address
Age
Name Address
Na
Has Health Workers Assist Patient
Assist Diagnose
Midwife
Name & Address Check up Form
1.0 2.0 3.0
Patient Register Process Diagnose
Submit Check up form 5.0 Check up form 4.0
Present Release Fo
Health Worker form to Receive by
claiming the patient
section
Check up Record Folder
6.0
Give medicine
put check-up Patient
ubmitted Form Claimed Medicine
form to folder
Name & Health Worker Name &
Address Address
1.4 Not a Residence 1.3 Name & Add
Referral Slip Refer to other In the Area
Patient Verify
Brgy. Health
Center Address
1.5 Residence
Blank Patient Record Name & In the Area
Form Add to Log Book/
Patient Give Patient
Form
Blank Patient Filled-out Patient Record
Form 1.6 Patient Form Name & Add
1.7
Filled-out
the Patient Present Form
to Health
Health Worker
Presented Patient Form
Form Worker
1.8
Presented
Check Patient Form
To 2.0 Validate to
Completeness
Name & Address Complete/
1.0 Valid Patient Form 2.0 Check-up Form 3.0
atient Register Process Diagnose
Submit Check-up Form 5.0 Check-up Form 4.0 Release Check u
Present Form
Receive by
Health Worker to Claiming
Section the Patient
Check up Record Folder
Check-up Info
mitted
up Form
6.0
Give medicine Claimed Medicine
put check-up Patient
form to folder