ITRGC Form DOCUMENT CODE: CHO.DHS.F.
001
Series of 2022
REPUBLIC OF THE PHILIPPINES
CITY HEALTH OFFICE
CITY OF DAVAO
RIVERSIDE HEALTH CENTER
INDIVIDUAL TREATMENT RECORD FOR GENERAL CONSULTATION (6 YRS AND ABOVE)
DATE OF VISIT: ______________ PHIC ID: ________________ NHTS-PR ID: ________________
NAME OF PATIENT: __________________________________________________ AGE: _____ GENDER: MALE / FEMALE
Last Name First Name Middle Name
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COMPLETE ADDRESS: ___________________________________________CONTACT NUMBER: ____________________
BIRTHDAY: __________________ RELIGION: ______________________ MARITAL STATUS: ______________________
EDUCATIONAL ATTAINMENT: __________________________________OCCUPATION: ___________________________
NAME OF ACCOMPANYING PERSON: _________________________________ RELATIONSHIP: _____________________
PERSONAL / SOCIAL HISTORY: FAMILY HISTORY: MEDICAL HISTORY:
1) SMOKER (___packs/year) YES NO 1) HYPERTENSION YES NO PREVIOUS SURGERIES: _________
2) DRINKS ALCOHOL(___bot/day) YES NO 2) DIABETES YES NO _____________________________
3) ILLICIT DRUG USE YES NO 3) GOITER YES NO _____________________________
4) MULTIPLE SEX PARTNERS YES NO 4) CANCER YES NO COVID 19 IMMUNIZATION STATUS
5) PWD ( SPECIFY: _________) YES NO 5) OTHERS: ________________
6) STI YES NO ________________________
7) ALLERGIES YES NO COITARCHE: _____ YRS OLD
__________________________________
MAINTENANCE MEDICINE ______________________________________________
FOR WOMEN ONLY: OB-GYNE HISTORY
OB SCORE: G ___ P ___ (FULLTERM ___, PRETERM ___, ABORTION ___, LIVING ___)
MENARCHE: ______ YRS OLD MENSTRUAL CYCLE: REGULAR / IRREGULAR, __________ FLOW LASTING FOR _____ DAYS
HISTORY OF PAP SMEAR YES / NO ( RESULT: ___________________________________)
FAMILY PLANNING METHOD USED: ____________________________________________
PERTINENT FINDINGS PER SYSTEM
HEENT HEART GENITOURINARY SKIN/EXTREMITIES
Essentially Normal Essentially Normal Essentially Normal Essentially Normal
Abnormal Pupillary reaction Displaced apex beat Blood stained in exam finger Clubbing
Cervical Lympadenopathy Heaves/trills Cervical dilatation Cold clammy
Dry mucous membrane Irregular rythm Presence of abnormal discharge Cyanosis/mottled skin
Icteric Sclerae Muffled heart sounds Others Edema/swelling
Pale Conjuctivae Murmurs Decreased mobility
Sunken eyeballs Pericardial bulge _______________________ Pail nailbeds
Sunken fontanelle Others Poor skin turgor
Others Rashes/Petechiae
_______________________ _______________________ Weak pulses
Others
CHEST/BREAST/LUNGS ABDOMEN DIGITAL RECTAL EXAMINATION NEUROLOGICAL EXAMINATION
Essentially Normal Essentially Normal Essentially Normal Essentially Normal
Asymmetrical Chest Expansion Abdominal rigidity Enlarge Prostate Abnormal gait
Decreased breath sounds Abdominal tenderness Mass Abnormal position sense
Wheezes Hyperactive bowel sounds Hemorrhoids Abnormal sensation
Lump over breasts Palpable mass(es) Pus Abnormal relex(es)
Crackels/rales Tympanitic/dull abdomen Not Applicable Poor/altered memory
Retractions Uterine Contraction Others Poor muscle tone/strength
Others Others Poor coordination
_______________________ Others
_______________________ _______________________ ___________________________
ITRGC Form DOCUMENT CODE: CHO.DHS.F.001
Series of 2022
REPUBLIC OF THE PHILIPPINES
CITY HEALTH OFFICE
CITY OF DAVAO
RIVERSIDE HEALTH CENTER
INDIVIDUAL TREATMENT RECORD FOR GENERAL CONSULTATION (6 YRS AND ABOVE)
PHILHEALTH ID: ________________
NAME OF PATIENT: ____________________________________________ AGE: ________ GENDER: MALE / FEMALE
Last Name First Name Middle Name
PATIENT’S CONSENT (PAGTUGOT SA PASYENTE)
IN ENGLISH SA BISAYA
I have read and understand the ITR (Individual Treatment Record) Ako nakabasa ug nakasabot sa ITR (Individual Treatment Record)
after I have been made aware of its content. During an paghuman na ako gipahibalo sa sulod niini ug gipasabot sa importansya
informational conversation, I was informed in a comprehensive sa Primary Care Benefits Package (PCB), Konsulta Program, eKonsulta
way about the need and importance of the Primary Care Benefits System ug iClinicsys (Integrated Clinic Information System) sa taga- CHO
Package (PCB), Konsulta Program, eKonsulta System, iClinicSys DHO/UHC. Tanan nakong pangutana kay natubag ug ako nahatagan ug
(Integrated Clinic Information System) by the CHO DHO/UHC saktong panahon para mahatag sa akoang pagtugot.
representative. All my questions during the said conversation
were addressed accordingly and I have also been given enough Ako pud ginahatagan ug permiso na isulod ang impormasyon sa akong
time to decide on this consent. pagkatao, sa estado sa akong panglawas ug sa nahimo ug mahimong
Furthermore, I permit CHO DHO/UHC to encode the information konsultasyon na mga information systems na nahisgot ug ang maong
concerning my person and the collected data regarding my health impormasyon ihatag sa Philippine Health Information Exchange – Lte
status and consultations conducted by the same on the (PHIE Lite), sa Department of Health (DOH) National Health Data
information systems mentioned above and provide the same to Reporting ug Philhealth Konsulta Program.
the Philippine Health Information Exchange – Lite (PHIE Lite), the
Department of Health (DOH) National Health Data Reporting and
Ang resulta sa akong konsultasyon ug estado sa akong panglawas kay
Philhealth Konsulta Program.
pwede nako mapangayo o sa akong tagtungod. Pwede rapud nako
I wish to be informed about the medical results concerning me
ikansela kining gihatag nako pagtugot sa CHO DHO/UHC na walay ihatag
personally or my direct descendants. Also, I can cancel my
na rason ug walay maski unsa na desbintaha sa akong medical na
consent at the CHO DHO/UHC anytime without giving reasons
pagtambal.
and without concerning any disadvantage for my medical
treatment.
SIGNED (PAGPIRMA)
DATE & TIME (ADLAW UG ORAS)
NAME AND SIGNATURE OF PATIENT
(PANGALAN UG PIRMA SA PASYENTE)
CONTACT NUMBER
NAME AND SIGNATURE OF FACILITY REPRESENTATIVE
(PANGALAN UG PIRMA SA REPRESENTANTE SA PACILIDAD)
DATE AND VITAL SIGNS CHIEF COMPLAINT SOAP
DATE:
HEIGHT:
WEIGHT:
BMI:
VITAL SIGNS:
BP:
HR:
RR:
TEMP:
FILLED-UP BY: NAME OF HEALTHCARE PROVIDER:
LABORATORY FINDINGS / PERFORMED LABORATORY TEST
IMPRESSIONS:
ITRGC Form DOCUMENT CODE: CHO.DHS.F.001
Series of 2022
REPUBLIC OF THE PHILIPPINES
CITY HEALTH OFFICE
CITY OF DAVAO
RIVERSIDE HEALTH CENTER
INDIVIDUAL TREATMENT RECORD FOR GENERAL CONSULTATION (6 YRS AND ABOVE)
PHILHEALTH ID: ________________
NAME OF PATIENT: ____________________________________________ AGE: ________ GENDER: MALE / FEMALE
Last Name First Name Middle Name
DATE AND VITAL SIGNS CHIEF COMPLAINT SOAP
DATE:
HEIGHT:
WEIGHT:
BMI:
VITAL SIGNS:
BP:
HR:
RR:
TEMP:
FILLED-UP BY: NAME OF HEALTHCARE PROVIDER:
LABORATORY FINDINGS / PERFORMED LABORATORY TEST
IMPRESSIONS:
DATE AND VITAL SIGNS CHIEF COMPLAINT SOAP
DATE:
HEIGHT:
WEIGHT:
BMI:
VITAL SIGNS:
BP:
HR:
RR:
TEMP:
FILLED-UP BY: NAME OF HEALTHCARE PROVIDER:
LABORATORY FINDINGS / PERFORMED LABORATORY TEST
IMPRESSIONS:
DATE AND VITAL SIGNS CHIEF COMPLAINT SOAP
DATE:
HEIGHT:
WEIGHT:
BMI:
VITAL SIGNS:
BP:
HR:
RR:
TEMP:
FILLED-UP BY: NAME OF HEALTHCARE PROVIDER:
LABORATORY FINDINGS / PERFORMED LABORATORY TEST
IMPRESSIONS:
DATE AND VITAL SIGNS CHIEF COMPLAINT SOAP
ITRGC Form DOCUMENT CODE: CHO.DHS.F.001
Series of 2022
REPUBLIC OF THE PHILIPPINES
CITY HEALTH OFFICE
CITY OF DAVAO
RIVERSIDE HEALTH CENTER
DATE:
HEIGHT:
WEIGHT:
BMI:
VITAL SIGNS:
BP:
HR:
RR:
TEMP:
FILLED-UP BY: NAME OF HEALTHCARE PROVIDER:
LABORATORY FINDINGS / PERFORMED LABORATORY TEST
IMPRESSIONS:
DATE AND VITAL SIGNS CHIEF COMPLAINT SOAP
DATE:
HEIGHT:
WEIGHT:
BMI:
VITAL SIGNS:
BP:
HR:
RR:
TEMP:
FILLED-UP BY: NAME OF HEALTHCARE PROVIDER:
LABORATORY FINDINGS / PERFORMED LABORATORY TEST
IMPRESSIONS:
DATE AND VITAL SIGNS CHIEF COMPLAINT SOAP
DATE:
HEIGHT:
WEIGHT:
BMI:
VITAL SIGNS:
BP:
HR:
RR:
TEMP:
FILLED-UP BY: NAME OF HEALTHCARE PROVIDER:
LABORATORY FINDINGS / PERFORMED LABORATORY TEST
IMPRESSIONS:
