HOUSEHOLD PROFILE

PHILIPPINE HEALTH AGENDA - FIRST 100 DAYS FORM

RECORDING FORM 1
HOUSEHOLD PROFILE

Date NHTS No.

Visited/Profiled
Province
Mun/City
Brgy

Name of NHTS Member and PhilHealth

Relation Birthday Age Sex Remarks
Dependents Member

(Last, First, Middle Name) M/F Y/N (Phil health no.) etc.
Form 1 TSeKaP Services

PHILIPPINE HEALTH AGENDA - FIRST 100 DAYS

RECORDING FORM

# Name Sex Physical Exam Weight Length Eye Exam Ear Exam Significant Findings

M F
1

2
3
4
5
6
7
Form 1 TSeKaP Services

FORM
1A
NEWBORN 0-28 DAYS

Remarks/Actions Taken
Form 2 TSeKaP Services

PHILIPPINE HEALTH AGENDA - FIRST 100 DAYS FORM

RECORDING FORM 1B
INFANT (29 days - 11 months)

# Name Sex Physical Length Weight Complete Blood Typing Urinalysis Stool Exam Eye Exam Ear Exam Significant Findings Remarks/Actions Taken
Exam Blood Count

M F Y/N cm kg Y/N Y/N Y/N Y/N Y/N Y/N

Form 3 TSeKaP Services

Physical Complete Blood Stool Oral

# Name Urinalysis Eye Exam Ear Exam Significant Findings Remarks/Action Taken
SEX Exam Blood Count Typing Exam Services

M F Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N

Form 4 TSeKaP Services

Complete Stool
# Name SEX Physical Exam Blood Typing Urinalysis Eye Exam Ear Exam Oral Services Significant Findings Remarks/Actions Taken
Blood Count Exam

M F Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N

5
Form 5 TSeKaP Services

F TSeKaP Services
# Name M
Complete
Pregnant Post Partum Non-Pregnant Physical Exam Weight Height Blood Pressure Blood Count Blood Typing Urinalysis Fasting Blood Sugar Stool Exam Family Planing Eye Exam Ear Exam Oral Exam Significant Findings Remarks/Actions Taken
Y/N kg cm Y/N Y/N Y/N Y/N Y/N Y/N w/ Unmet need Counseling Commodities Y/N Y/N Y/N
Form 6 TSeKaP Services

F
# Name M Blood Complete Blood
Pregnant Post Partum Non-Pregnant Physical Exam Weight Height Pressure Count Blood Typing

Y/N kg cm Y/N Y/N Y/N

Form 6 TSeKaP Services
Form 6 TSeKaP Services
Form 6 TSeKaP Services
Form 6 TSeKaP Services

Men 20-49 y/o

Form 6 TSeKaP Services

TSeKaP Services
Urinalysis Fasting Blood Sugar Stool Exam Family Planing

Y/N Y/N Y/N w/ Unmet need Counseling

Form 6 TSeKaP Services
Form 6 TSeKaP Services
Form 6 TSeKaP Services
Form 6 TSeKaP Services
Form 7 TSeKaP Services

PHILIPPINE HEALTH AGENDA - FIRST 100 DAYS FORM

RECORDING FORM 1G
50-59 y/o

# Name Sex PE Height Weight BP CBC Blood Typing Blood Sugar Urinalysis Stool Eye Exam Ear Exam Oral Services Significant Findings Remarks/Actions Taken
Test Exam

M F Y/N cm kg Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N fbs
Form 7 TSeKaP Services

PHILIPPINE HEALTH AGENDA - FIRST 100 DAYS FORM

RECORDING FORM 1H
60 y/o and Above

# Name Sex PE Height Weight BP CBC Blood Typing Blood Sugar Urinalysis
Test
Stool
Exam Eye Exam Ear Exam Oral Services Significant Findings Remarks/Actions Taken

M F Y/N cm kg Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N