SDEAS 2 FP FORM 1 [FAMILY PLANNING CLIENT ASSESSMENT RECORD CLIENT ID: instructions for Prysiors, Nufses and tikaivas: Make aure that the cllant Is not pregnant By PHILMEALTH NO: Jesing the questions listed In SIDE B. Computy flout or check ha requed hformatin. Refer | Nurs? Yes CONE yocoreingly for any soncrmat htonyTien gs for Ror medical watt i (NAME OF CLIENT: s Losthiarre ‘Given Name wi ‘hoe ‘Cocupaton ‘ADORESS: No ‘Barangay MunkpalyiGy —-Provinco Contact Nurrbor Religion [NAME OF SPOUSE: LastName ‘Gren Nar ww ‘Conia [NO.OF LIVING CHILOREN: PLAN TO HAVEMORE CHILDREN? ©) Yer No __ AVERAGE MONTHLY INCOME: ‘Type of Cent Now Acceptor —-»-Resson be FP: C2 spacing C1 tming Coners___._ Previously used Maha (fr Current User: 1D Current user Reason bc FP: OD spacing ©) knog 2 obors Dinpet =O BTL ONSY GChanong Menod Reason C] medealconesion (I se-otoct Dinpcsle CACOC —CIPOP Condom 2.Changng Cine cum OSM ssT DeowoMMSTM 2 dropout Restrt 1. MEDICAL HISTORY TW. RISKS FOR WOLENCE AGAINST WOMEN (VAW) ‘Toes ne cient have any oft blowns? "= TEiy ofdoreste cienee oF VAT Tver GINO = savore boadaches mgrane ayer No | = unpleasantreiatonship wih parmer Yes Ne ‘= hesory of stoke /noartatock/ hyperension Bayes No | « parmer éoos not approve the vistio FP cine CaYes Ne |= ron-rauratc hemmbma Faquentbruisng or gumblesding Yes Ne Rebrrede: C080 ‘= aurrentor nstory of reast cance breast ass Gyes Oho caMcru = savere chest pan Byes No NGOs ‘= cough fer more tan 14 days, Gves No 1 Ohers (Speci: = pundes - ayes ONo [Wo PHYSICAL EXAMINATION ‘= unexpianed vopnal biveding yes GNo | Wegnt ig Good press onto ‘= sperma vagnal decharge coyes No | Hott Paso rate: ia ‘= ibke ofphencbarveal (ant-selure) or rtamplen (on-TS) Yes No | SKIN: EXTREMITIES, ‘= Is ro cionta SMOKER? yes No | normal Dinos = Win Deabity? yes oNo | Cpa. § Bedera (EVES pleco specty- = —————————) | Oyetowen 0 varcosies [C"IDOBSTETRICALHISTORY. Chemaiora PELVIC EXAMINATION Wonber ofpregnances 6. F ‘CONJUNCTIVA: (For 1U0 Ascepiors) Fol __ Premeure Gnormat G norral poeton wing enttron Cpa Ones Dan ofestdewery IL Byetowen 1D sonora wtcharge Type ollaadeWvery Cvagnal CiCesareen Secton Neck: 1D oxrvical abnoemaos Lasteensrvalpered I nore wars Prevous monstualperied | Cineck mess: D poyp or ayst Mensrval tow G onisrged lymph nodes 1D infanraton or erosion ‘oscany (1-2 pads per 37) BREAST: a biody achorge ‘Clrocerat (3-5 pads par cay) norma 1 cxrvcal constny Ghoavy (>5 per pads day) Cass, Dim Co sot ‘Doysrenormee, ‘D nople iseherge (C oxrvicot ondernass (Dy dattorm mole {witin he st 12 mons) ‘ABDOMEN C adnexal mass / endernass CD Hisery otectopic prognancy Doral uterine poston: | TTWT RISKS FOR SEXUALLY TRANSMITTED INFECTIONS | abdominal ase Oma ‘Dows he Glantor he cents parmer have any ofthe Bowing? vercostos CD anetexed ‘+ abnormal discharge tom he goat area yes ONe Drovotexed I-YES" please ndcate rom: CIvagha OPens, 1 urine dept: em (# sor0s or ules in re gant aes Caves No | AGRNOWLEDGEMENT: “= pain or burning sensaton he genio! ares Caves ONo | This conty mat ng PhyskdorNuree/Midwile of he Cénie Nes ty inecoey of rearenttor soxuaty Fansmasd [BYes GNo | explained 19 mo he ferent menads avatable in Sey plonning ané | tnkactons teety croos0 m0, ‘method. HIV/AIDS /PeWc ntemratry doa Yes Ne ClentSignaure Dae Impint= Pogstn etenalimglee 1D» Invetene doce: OT Bitar! bal tgatin:6V= | | hareby consont oe Ision of my FP Form { ho Fam Healt " iy S06 = Combi ert canracagves: POP Prozeatin lye; A= | Regi. Q eacitane amerorhee metoc. SOM = Sanders oey2 method, GOT = Base! tc empire; BOM ‘Binge cvsaion mathad CHUM # Carica micus mat. STM Syeplicme! method Giant Snare a)FP FORM 1 SIDE B. FAMILY PLANNING CLIENT ASSESSMENT RECORD NAMEANO | DATEOF ages MEDICAL, FINDINGS METHOD | SIGNATURE OF | FOLLOW-UP wsit (ttecia ooservafon conpicint eorotcaton, sevice rendered procedures, | AgcEPTED Tenice aa porary exarinfon,Festrantand ampore Storey eta Sr | PROVDER | (mwoore”~) { Howto be Reasonably Sure Glientls Not Pregnant “ Didyeu have a baby less than se (6) mons go, ar you MY OF nary Breasooding, AND hove you Dye oN hia no mort period since hen? 2, Haveyou abstned Fem soratinercouree sng yout lat mene prod or doWory? oye ON 5, Have you hed ababy nto laetfur (4) wooks? Byes Ot 4 Disyourtestmensrua period startin te pastsvon (7) evs? Ove Ne 5. Haveyou hae arsoarriog or aborton in he stoovén (7) dys? Oye One 6, Have you been wg elle contaceptve rod consent end corecty? Ove Ne sho font nauwered YES b stloast one ene quastors snd sels to etigs or symptrs ef prognancy. Provide cnt wh dest ed meth. ‘Titme dentovewored NO b a othe quests, pregnancy connote red out The clnt shoud awattmenses of Use 9 pregnancy BF