Rural Health Unit - ___ BHS; ___________________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 SERVICESPrimary Preventive Services Frequency Date Performed
1st Qtr 2nd Qtr 3rd Qtr 4th Qtr
1. BP Measurements Hypertensive Once a month Non-Hypertensive Once a year2. Periodic Clinical Breast Examination Once a year3. Visual Inspection with Acetic Acid Once a year
DIAGNOSTIC EXAMINATION SERVICES Part I.
Date Diagnosis Type Given Referred Remarks
OTHER PCB1 SERVICES
Date Diagnosis Type Remarks
OTHER SERVICESDate Diagnosis Type Remarks
PHILIPPINE HEALTH INSURANCE CORPORATION
Municipal Health OfficeCalasiao, Pangasinan
PCB PATIENT LEDGER
ANNEX A3
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