ANNEX A1

PHILIPPINE HEALTH INSURANCE CORPORATION

_____________________________________________________
(Name of PCB Provider)

INDIVIDUAL HEALTH PROFILE

Print legibly. Mark appropriate boxes c with " " PIN:

Patient Name:
(Last Name) (First Name) (Middle Name) (Extension: Sr., Jr., e
Note: If this is a follow-up consult or 2nd visit, please indicate if there are any changes in the Basic Demograph
Updating of this Individual Health Profile must be done before the fiscal year ends, to include review of consul
records (Annex A.3) Indicate the date when the new data has been entered. Please use additional page when n
Address:
Age: 0 1 year 2 - 5 years 6 - 15 years 16 - 24 years 25 59 years 60 years and
Birthdate:
(mm/dd/yyyy)
/ / Sex: Male
Female
Religion:

Civil Status: Single Married Annuled Widowed Separated Others, specify ____
PHIC Membership: Type of Membership
Member Sponsored Individually Paying Program (IPP) Employed
Dependent NHTS LGU Organized Group Government
Non-Member NGA Private OFW Private
Occupation: _______________________________________________________________________________
Highest Completed Educational Attainment:
College degree,post graduate High School Elementary Vocational
Past Medical History:
Allergy, specify _____________________ Emphysema Pneumonia
Asthma Epilepsy/Seizure disorder Thyroid disease
Cancer, specify organ_______________ Hepatitis, specify type ____________ Tuberculosis, specify organ _
Cerebrovascular disease Hyperlipidemia If PTB, what category? _____
Coronary artery disease Hypertension, highest BP ________ Urinary tract infection
Diabetes mellitus Peptic ulcer disease Others: _________________
Past Surgical History:
Operation: _____________________________________________ Date: _______________________
Operation: _____________________________________________ Date: _______________________
Family History:
Allergy, specify _____________________ Emphysema Thyroid disease
Asthma Epilepsy/Seizure disorder Tuberculosis, specify organ _
Cancer, specify organ_______________ Hepatitis, specify type ____________ If PTB, what category? _____

Page 1 of 21
 Cerebrovascular disease Hyperlipidemia Others: _________________
Coronary artery disease Hypertension
Diabetes mellitus Peptic ulcer disease
Personal/Social History:
Smoking: Yes No Quit No. of pack years? _______________
Alcohol: Yes No Quit No. of bottles/day? _______________
Illicit drugs: Yes No

Page 2 of 21
Immunizations:
For children: BCG OPV1 OPV2 OPV3 DPT1 DPT2
Measles Hepatitis B1 Hepatitis B2 Hepatitis B3 Hepatitis A Varicella (Chic

For young women: HPV MMR For pregnant women: Tetanus toxoid
For elderly and immunocompromised: Pnuemococcal vaccine Flu vaccine
Others: Specify ______________________________________________________________________________
Menstrual History:
Menarche: _________ Onset of sexual intercourse: _________
Last Menstrual Period: ________ Birth control method: _________________
Period Duration: ________ Interval/Cycle: ________ Menopause? Yes No
No. of pads/day during menstruation:________ If yes, at what age?: _________
Pregnancy History:
Gravity(no. of pregnancy): ________ Parity(no. of delivery): _________ Type of Delivery: ___
# of Full term: ________ # of Premature: ______ # of Abortion: _____ # of Living Children: ___
Pregnancy-induced hypertension(Pre-eclampsia)
Access to Family Planning counseling: Yes No
Pertinent Physical Examination Findings:
BP:______________ Height:_________(cm)
HR:______________ Weight:_________(kg)
RR:______________ Waist circumference(cm):________________
Skin: pallor rashes jaundice
__________________________________________________________________________________
__________________________________________________________________________________________
HEENT: anicteric sclerae intact tympanic membrane tonsillopharyngeal congestion
pupils briskly reactive to light alar flaring hypertrophic tonsils
aural discharge nasal discharge palpable mass
__________________________________________________________________________________
__________________________________________________________________________________________
Chest/Lungs: symmetrical chest expansion retractions wheezes
clear breathsounds crackles/rales
_______________________________________________________________________________
_______________________________________________________________________________
Heart: adynamic precordium normal rate regular rhythm heaves/thrills
__________________________________________________________________________________
__________________________________________________________________________________________
Abdomen: flat flabby tenderness
globular muscle guarding palpable mass
__________________________________________________________________________________
__________________________________________________________________________________________

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Extremities: gross deformity normal gait full and equal pulses
_______________________________________________________________________________
______________________________________________________________________________________

Page 4 of 21
___

(Extension: Sr., Jr., etc.)

he Basic Demographic Data.
ude review of consultation
ditional page when necessary.

60 years and above

Others, specify ______________

Employed Lifetime
Government
Private
_____________________

No Schooling

culosis, specify organ ________

, what category? _____________
ry tract infection
s: __________________________

_____________
_____________

culosis, specify organ ________

, what category? _____________

Page 5 of 21
s: __________________________

______________
_______________

Page 6 of 21
 DPT2 DPT3
Varicella (Chicken Pox)

_______________________

urse: _________
________________

Type of Delivery: _________

Living Children: __________

good skin turgor

________________________
______________________________
ngeal congestion exudates

____________________
___________________________

_____________________
_____________________
murmurs
____________________
___________________________

____________________
___________________________

Page 7 of 21
equal pulses
_______________________
______________________________

Page 8 of 21
 ANNEX A2
PHILIPPINE HEALTH INSURANCE CORPORATION
PCB PROVIDER CLIENTELE PROFILE

I. PCB Provider Data ______________________________________

NAME OF HEALTH CARE FACILITY
Region
II. Age - Sex Distribution III. Primary Preventive Services # Members and Dependents
Province Age Group Members and Dependents Member Dependents
Male Female Total Breast Cancer Screening
City/Municpality 0 - 1 years Female, 25 years old and above
2 - 5 years Cervical Cancer Screening
No. of assigned families: 6 - 15 years Female , 25 to 55 years old with
SP - NHTS:_________________ 16 - 24 years intact uterus
SP - LGU:__________________ 25 - 59 years
SP - NGA:_________________ 60 years and above
SP - Private:_______________
IPP - OG:__________________ TOTAL
IPP - OFW:________________
Non-PHIC Members: _______
IV. Hypertension # of Members and Dependents
III. Diabetes Mellitus # of Members and Dependents Members Dependents
Member Dependent Total Cases Female Female Total
Cases Male Non Male Non
Pregn Pregn
M F M F M F ant Pregnant ant Pregnant
with symptoms/signs of polyuria, Adult with BP < 140/90 mmHg
polydipsia, weight loss Adult with BP >/= 140/90 but
Waist circumference less
Adultthan
with180/120mmHg
BP > 180/120
80 cm (female) mmHg
90 cm (male) History of diagnosis of
History of diagnosis of diabetes hypertension
Intake of oral hypoglycemic agents Intake of hypertension medicine

Prepared by: Approved by:

________________________________________________
Printed name and signature of Nurse/ Midwife Printed name and signature of Physician
ANNEX A3 Part II.
PHILIPPINE HEALTH INSURANCE CORPORATION equivale
PCB PATIENT LEDGER
Date

NAME OF HEALTH CARE FACILITY

Part I
Name: ______________________________________________ Age: _____________ Sex: ___________
Address: ____________________________________________ PIN: _________________________
`
( ) PHIC Sponsored IPP Employed ( ) Lifetime
( ) Member ( ) NHTS ( ) LGU ( ) OG ( ) Government
( ) Dependent ( ) NGA ( ) Private ( ) OFW ( ) Private
( ) NON PHIC ( ) Voluntary/self employed
OBLIGATED SERVICES
Date Performed
Primary preventive services Frequency
1st Qtr 2nd Qtr 3rd Qtr 4th Qtr
1. BP measurements
Hypertensive Once a month
Nonhypertensive Once a year
2. Periodic clinical breast Once a year
examination
3. Visual inspection with acetic Once a year
acid

PART I. DIAGNOSTIC EXAMINATION SERVICES

Date Diagnosis Type Given Referred Remarks

OTHER PCB1 SERVICES

Date Diagnosis Type Remarks

OTHER SERVICES
Date Diagnosis Type Remarks
Part II. Please use this part for consultation of illness/well check-up (FP, immunization, etc.). You may use any
equivalent ledger in your facility
Treatment/
Date History of Present Illness Physical Exam Assessment/Impression
Management Plan
 ANNEX A4
PHILIPPINE HEALTH INSURANCE CORPORATION
QUARTERLY REPORT FORM
___________________________________________________________
NAME OF PCB PROVIDER
HEALTH FACILITY DATA
SUMMARY OF BENEFITS AVAILMENT (Members and Dependents)
I. Covered Period IV. Obligated Services
From
To TARGET Accomplishment
OBLIGATED SERVICES
(for the quarter) (number)
II. PCB Participation No. Primary preventive services
1. BP measurement
Hypertensive
Nonhypertensive
III. Municipality/City/ Province 2. Periodic clinical breast examination
3. Visual inspection with acetic acid

No. of Members/
V. Members and Dependents Served VI. BENEFITS/SERVICES PROVIDED Dependents VII. Medicines Given No. of Members/
Male: Female: TOTAL Given Referred (Generic Name) Dependents
Members: Primary Preventive Services M D M D I. Asthma M D
Dependents: 1. Consultation
TOTAL 2. Visual inspection with acetic acid
3. Regular BP measurements II. AGE with no or mild dehydration
VIII. Top 10 Common Number of 4. Breastfeeding program education
Illnesses (Morbidity) Cases 5. Periodic clinical breast examinations
6. Counselling for lifestyle modification
7. Counselling for smoking cessation
8. Body measurements III. URTI/Pneumonia (minimal & low risk)
9. Digital rectal examination
Diagnostics Examinations
1. Complete blood count (CBC)
2. Urinalysis IV. UTI
3. Fecalysis
4. Sputum miroscopy
5. Fasting blood sugar (FBS) V. Nebulisation services
 6. Lipid profile
IX. CERTIFICATION 7. Chest x-ray

This is to certify that the foregoing information are true and correct and all of the beneficiaries served are assigned and enlisted under our facility.

Prepared by: Approved by:

____________________________________________________ ________________________________________________
Printed name and signature of Nurse/ Midwife Printed name and signature of Physician
H INSURANCE CORPORATION
RLY REPORT FORM
__________________________________
OF PCB PROVIDER
TH FACILITY DATA
VAILMENT (Members and Dependents)

Accomplishment
(number)

No. of Members/
Dependents
D

II. AGE with no or mild dehydration

III. URTI/Pneumonia (minimal & low risk)

IV. UTI

V. Nebulisation services
beneficiaries served are assigned and enlisted under our facility.

________________________________________________
ANNEX A5
Philippine Health Insurance Corporation
PCB FORM 1A
QUATERLY SUMMARY OF PCB SERVICES PROVIDED
_________________________________________________________
NAME OF HEALTH CARE PROVIDER

PATIENT BENEFITS GIVEN (Number of times benefit given) Medicines Given

Visual inspection with acetic

Regular BP measurement

Counselling for smoking

Counselling for lifestyle
Breastfeeding program

Periodic clinical breast

Body measurements

Sputum Microscopy
Digital rectal exam
Membership

Consultation

modification
examination

Lipid profile

Chest x-ray
education

Urinalysis
cessation

Fecalysis
PHILHEALTH
Date NAME SEX AGE DIAGNOSIS

acid

CBC

FBS
NUMBER

1 M
D M
F
2 M
D M
F
3 M
D M
F
4 M
D M
F
5 M
D M
F
6 M
D M
F
7 M
D M
F
8 M
D M
F
9 M
D M
F
10 M
D M
F
11 M
D M
F
12 M
D M
F
13 M
D M
F
14 M
D M
F
15 M
D M
F

TOTAL

This is to certify that the foregoing information are true and correct and all of the beneficiaries served are assigned and enlisted under our facility .

Prepared by: Approved by:

Printed name and signature of Nurse/ Midwife Printed name and signature of Physician