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CHD4A-FamilyProfile-Form2.Rev0
Republic of the Philippines
Department of Health
CENTER FOR HEALTH DEVELOPMENT
CaLaBaRZon
QMMC Compound, Project 4, Quezon City
Trunkline: (02)990.4032/Direct Line: (02) 440.3551/440.3372
Email Add: chd4a_doh_calabarzon@yahoo.com
Municipality/City:
Family Name Sex Address Date Profiled Interventions/Assistance Needed** Actions Taken
Age Barangay Health Condition/Problem*
(Surname, First Name, Middle Name) (M,F) (House No., Street, Purok) (mm/dd/yyyy) from RHU/CHO from Other HF-Name*** from Other HF-Intervention from CHD c/o RHU/CHO/NDP c/o Other HF-Name*** c/o Other HF-Action Taken
HPN; submandibular swelling (L) for two consultation due to submandibular walker/wheelchair to assist in referred for consultation on
*dela Cruz, Juan Castillo 70 M 25 Lakandula St. Brgy. Poblacion II 6/9/2019 Mount Grace Hospital consultation with ENT
days, with pain (4/10) swelling, left ambulation (date)
dental services
maintenance meds for HPN
maintenance meds for HPN Management for fever (38.7 C) -
*dela Cruz, Juana Rosario 64 F 4-a Lot 2 Phase 1 Brgy. As-Isan 6/9/2019 HPN; fever for 2 days
(losartan + HCTZ) TSB and paracetamol
*Health condition/problem is not always a disease/diagnosis, but also consider what the client has been complaining for a time period.
**Do not limit interventions/assistances based on the current health condition/problem, but also from other observations that may be noted during profiling. Interventions/assistances may be health education/advocacies, referrals, VS takings, commodities, among .others
***Indicate the name of health facility, intervention needed and actions taken.
Municipality/City:
Family Name Sex
Age
(Surname, First Name, Middle Name) (M,F)
Date
Address
Profiled
(House No., Street, Barangay
(mm/dd/yy
Purok)
yy)
Republic of the Phi
Department of H
CENTER FOR HEALTH D
CaLaBaRZo
QMMC Compound, Project 4
Trunkline: (02)990.4032/Direct Line: (
Email Add: chd4a_doh_calabar
HEALTH CONDITION/PROBLEM
Health Condition/Problem*
from RHU/CHO
Republic of the Philippines
Department of Health
CENTER FOR HEALTH DEVELOPMENT
CaLaBaRZon
QMMC Compound, Project 4, Quezon City
Trunkline: (02)990.4032/Direct Line: (02) 440.3551/440.3372
Email Add: chd4a_doh_calabarzon@yahoo.com
Interventions/Assistances Needed**
from Other HF-Name*** from Other HF-Intervention
Actions Tak
from CHD c/o RHU/CHO/NDP
CHD4A-FamilyProfile-Form2.Rev0
Actions Taken
c/o Other HF-Name*** c/o Other HF-Action Taken
Municipality/City:
Family Name Age Sex
(Surname, First Name, Middle Name) (M,F)
JARINA,ADELAIDA PEREZ 70 F
HEALTH CONDITION/PROBLEM
10/7/2019 HPN
10/7/2019 HPN
10/7/2019 HPN
DM
10/7/2019 ANEMIA
10/7/2019 HPN
UTI
10/7/2019 COUGH
10/7/2019 GOITER
10/7/2019 HPN
10/7/2019 HPN
10/7/2019 COUGH
10/7/2019 HPN
10/7/2019 ASTHMA
10/7/2019 FEVER AND COUGH
10/7/2019 HPN
BP: 130/80
10/7/2019 HPN
10/7/2019 HPN
HEART DISEASE
10/7/2019 ASTHMA
10/7/2019 COUGH
10/7/2019 HPN
10/7/2019 ASTHMA
10/7/2019 EPILEPTIC
10/7/2019 MALNOURISHED
WITH 1ST DEGREE BURN AT CHEST
COUGH
ventions/assistances may be health education/advocacies, referrals, VS takings, commodities, among .others
Republic of the Philippines
Department of Health
CENTER FOR HEALTH DEVELOPMENT
CaLaBaRZon
QMMC Compound, Project 4, Quezon City
Trunkline: (02)990.4032/Direct Line: (02) 440.3551/440.3372
Email Add: chd4a_doh_calabarzon@yahoo.com
Interventions/Assistances Neede
from RHU/CHO from Other HF-Name***
MAINTENANCE FOR HPN ARANAS MEDICAL CLINIC
LOSARTAN; AMLODIPINE
ATORVASTATIN; ASPIRIN
FERROUS SULFATE
MEDICATIONS FOR HEART DISEASE
IBERET; MEDIFAORTAN
MVM +IRON
MAINTENANCE FOR HPN ST. VINCENT DE PAUL HOSPITAL
LOSARTAN
OMEPRAZOLE; CEFIXIME;
(+) PALPITATION
(+) DOB
AUSCULTATION DONE
CLEAR BREATH SOUNDS
MAINTENANCE FOR HPN
AMLODIPINE
REFER TO RHU 2
PALE; WEAK
AUSCULTATION DONE (+) CRACKLES
WOUND DRESSING DONE
akings, commodities, among .others
/Assistances Needed**
from Other HF-Intervention from CHD
CONSULTATION WITH IM MAINTENANCE FOR HPN
LOSARTAN; AMLODIPINE
ATORVASTATIN; ASPIRIN
IBERET; MEDIFAORTAN
MVM +IRON
CONSULTATION WITH IM MAINTENANCE FOR HPN
LOSARTAN
OMEPRAZOLE; CEFIXIME;
LAGUNDI TAB
REFER TO RHU 2
PARACETAMOL SYRUP
ORS GIVEN
REFER TO RHU 2
DIET MODIFICATION
ADVISED FOLLOW-UP CHECKUP
HEALTH TEACHINGS
DIET MODIFICATION
ADVISED FOLLOW-UP CHECKUP
HEALTH TEACHINGS
BP MONITORING C/O BHW
RBS MONITORING C/O MIDWIFE
DIET MODIFICATION
ADVISED FOLLOW-UP CHECKUP
HEALTH TEACHINGS
BP MONITORING C/O BHW
RBS MONITORING C/O MIDWIFE
DIET MODIFICATION
ADVISED FOLLOW-UP CHECKUP
HEALTH TEACHINGS
DIET MODIFICATION
ADVISED FOLLOW-UP CHECKUP
HEALTH TEACHINGS
BP MONITORING C/O BHW
INCREASE OFI
DIET MODIFICATION
ADVISED FOLLOW-UP CHECKUP
HEALTH TEACHINGS
INCREASE OFI
WOF DOB, DECREASE APPETITE
AND FEVER
INCREASE OFI
DIET MODIFICATION
ADVISED FOLLOW-UP CHECKUP
HEALTH TEACHINGS
WOF DOB, FEVER AND
DECREASE APPETITE
DIET MODIFICATION
ADVISED FOLLOW-UP CHECKUP
HEALTH TEACHINGS
WOF DOB AND WHEEZES
DIET MODIFICATION
ADVISED FOLLOW-UP CHECKUP
HEALTH TEACHINGS
WOF DOB, FEVER AND
DECREASE APPETITE
INCREASE OFI
DIET MODIFICATION
ADVISED FOLLOW-UP CHECKUP
HEALTH TEACHINGS
WOF DOB, FEVER AND
DECREASE APPETITE
INCREASE OFI
ADVISED FOLLOW-UP CHECKUP
HEALTH TEACHINGS
DIET MODIFICATION
BP MONITORING C/O BHW
DIET MODIFICATION
ADVISED FOLLOW-UP CHECKUP
HEALTH TEACHINGS
WOF DOB, FEVER AND
DECREASE APPETITE
INCREASE OFI
DIET MODIFICATION
ADVISED FOLLOW-UP CHECKUP
HEALTH TEACHINGS
WOF DOB, FEVER AND
DECREASE APPETITE
INCREASE OFI
CHD4A-FamilyProfile-Form2.Rev0
n
c/o Other HF-Action Taken
Municipality/City:
Family Name Age Sex
(Surname, First Name, Middle Name) (M,F)
HEALTH CONDITION/PROBLEM
10/9/2019 HPN
10/9/2019 HPN
10/9/2019 HPN
DM
HEART PROBLEM
10/9/2019 HPN
10/9/2019 HPN
ASTHMA
HEART PROBLEM
10/9/2019 HPN
10/9/2019 PTB
10/9/2019 GOITER
10/9/2019 DM
10/9/2019 HPN
10/9/2019 HPN
DM
10/9/2019 HPN
10/9/2019 FEVER
10/9/2019 HPN
10/9/2019 INCREASE BP
ASTHMA
10/9/2019 COUGH
10/9/2019 HYPERACIDITY
ENLARGED PROSTATE
10/9/2019 DM
10/9/2019 INCREASE BP
BP; 140/80
10/9/2019 DM
10/9/2019 CONGENITAL KIDNEY FAILURE
10/9/2019 SORETHROAT
10/9/2019 EPILEPSY
10/9/2019 ASTHMA
MASS ON NECK
10/9/2019 ARTHRITIS
10/9/2019 HPN
DM
10/9/2019 GOITER
10/9/2019 GOITER
DM
ventions/assistances may be health education/advocacies, referrals, VS takings, commodities, among .others
Republic of the Philippines
Department of Health
CENTER FOR HEALTH DEVELOPMENT
CaLaBaRZon
QMMC Compound, Project 4, Quezon City
Trunkline: (02)990.4032/Direct Line: (02) 440.3551/440.3372
Email Add: chd4a_doh_calabarzon@yahoo.com
Interventions/Assistances Neede
from RHU/CHO from Other HF-Name***
MAINTENANCE FOR HPN ARANAS MEDICAL CLINIC
AUSCULTATION DONE
LAGUNDI TAB; MVT
TB-DOTS MEDICATIONS
LANOXIN; FUROSEMIDE
FOLLOWUP AT HEART CENTER ON 11-29-19
VENTOLIN INHALER
AUSCULTATION DONE
LAGUNDI TAB
ADVISED FOLLOW UP TO AP
MAINTENANCE FOR DM
METFORMIN
DIALYSIS 2X A WEEK
FESO4; BONCARE D BCOMPLEX
TAMSULOSIN
CEFIXIME SYRUP
ERCEFLORA
MAINTENANCE FOR DM
METFORMIN
LEVOTHYROXINE; XELEVIA
akings, commodities, among .others
/Assistances Needed**
from Other HF-Intervention from CHD
CONSULTATION WITH IM MAINTENANCE FOR HPN
ADEFLO
TB-DOTS MEDICATIONS
DIGOXIN TAB
VENTOLIN INHALER
LAGUNDI TAB
ADVISED FOLLOW UP TO AP
CEFIXIME SYRUP
ERCEFLORA
MAINTENANCE FOR DM
METFORMIN
LEVOTHYROXINE; XELEVIA
Actions Taken
c/o RHU/CHO/NDP c/o Other HF-Name***
ADVISED FOLLOW-UP CHECKUP
HEALTH TEACHINGS
DIET MODIFICATION
BP MONITORING C/O BHW
DIET MODIFICATION
ADVISED FOLLOW-UP CHECKUP
HEALTH TEACHINGS
WOF DOB, FEVER AND
DECREASE APPETITE
INCREASE OFI
DIET MODIFICATION
ADVISED FOLLOW-UP CHECKUP
HEALTH TEACHINGS
WOF DOB, FEVER AND
DECREASE APPETITE
INCREASE OFI
HEALTH TEACHINGS
DIET MODIFICATION
ADVISED FOLLOW-UP CHECKUP
SAFETY PRECAUTIONS
HEALTH TEACHINGS
DIET MODIFICATION
ADVISED FOLLOW-UP CHECKUP
SAFETY PRECAUTIONS
n
c/o Other HF-Action Taken
Municipality/City:
Family Name Age Sex
(Surname, First Name, Middle Name) (M,F)
*Health condition/problem is not always a disease/diagnosis, but also consider what the client has been complai
**Do not limit interventions/assistances based on the current health condition/problem, but also from other obse
***Indicate the name of health facility, intervention needed and actions taken.
Address Barangay
(House No., Street, Purok)
t also consider what the client has been complaining for a time period.
ealth condition/problem, but also from other observations that may be noted during profiling. Interventions/assistances ma
actions taken.
Republic of the Philippin
Department of Health
CENTER FOR HEALTH DEVE
CaLaBaRZon
QMMC Compound, Project 4, Que
Trunkline: (02)990.4032/Direct Line: (02) 4
Email Add: chd4a_doh_calabarzon@
HEALTH CONDITION/PROBLEM AN
Interventions/Assistances Needed*
from RHU/CHO from Other HF-Name***
akings, commodities, among .others
/Assistances Needed**
from Other HF-Intervention from CHD
Actions Taken
c/o RHU/CHO/NDP c/o Other HF-Name***
CHD4A-FamilyProfile-Form2.Rev0
n
c/o Other HF-Action Taken