Escolar Documentos
Profissional Documentos
Cultura Documentos
REC-006-Jul2013-Rev0
DEPARTMENT OF HEALTH
Integrated Chronic Non-Communicable Disease Registry System
Out-patient
Referred, Referring Facility ________________________
Walk-in
6 Type of Patient
7 Name of Patient*
Last Name
First Name
In Patient
Referred, Referring Facility _____________________
Walk-in
8 Sex*
Female
Male
9 Civil Status
Single
Widow/er
Co-Habitation
Divorced
Middle Name
Married
Separated
Annulled
First Name
Middle Name
11 Permanent Address
____________________ _________ _____________________ _____________________ _________________
Number & Street Name
Region
Province
City/Municipality
12 Landline #
__________
Barangay
Zip Code
13 Birth Date *
____/____/____
mm dd yyyy
Region
Province
City/Municipality
14 If Date of Birth
____Yrs ____ Mos ____ Days
Zip Code
22 Company
First Name
Region
Province
City/Municipality
16 Religion
18 Race
17 Nationality
19 Ethnicity
23 PhilHealth #
23a Common
Reference #
24b Landline #
Middle Name
24a Address
_________________ _________ _________________ _________________ _______________ __________
Number & Street Name
__________
Barangay
21 Occupation
12a Mobile #
Barangay
24c Mobile #
Zip Code
PATIENT HISTORY
dd
26 Chief Complaint:
yyyy
Acquired
with Glasses
Can be tested
Low Vision
Blind
Cannot be tested: Believed blind
Believed not blind
Refraction
30 Causes of Low Vision or Blindness
30a Refractive Error
Myopia
Hyperopia
Astigmatism
Mixed
Presbyopia
Amblyopia
30b Disorders
Physical, Disorganized or Absent Globe
Cataract (if checked, answer item nos. 33-36)
Uncorrected Aphakia
Corneal Opacity
Anterior Uveitis
Glaucoma
Optic Atrophy
Retinopathy
Chorioretinitis
Macular Degeneration
Retinal Detachment
Tumors
Right Eye
Left Eye
Acute
Gradual
Unknown
Right Eye
Left Eye
Right Eye
Left Eye
Right Eye
Left Eye
DEPARTMENT OF HEALTH
Integrated Chronic Non-Communicable Disease Registry System
Not Examined
31 Prognosis of Vision Loss:
Treatable
Guarded/Progressive
Untreatable
Unknown
32 Prosthetic Device
Eye Glasses
Contact Lenses
Prosthetic Eye(s)
Other (specify) __________________________
For CATARACT Case
33 Type of Cataract
Primary
Senile/Age related
Congenital
Developmental
Secondary
Trauma
Infection
Surgery-induced
Glaucoma
Others, specify_________
35 Date of Operation____/____/_____
mm
dd
Right Eye
With
Without
IOL
IOL
Left Eye
yyyy
Left Eye
With
Withou
IOL
t IOL
ICCE
ECCE
SICS
PHACO
IOL
First Name
Middle Name
____________________
39c Landline #
Department
Region
Province
City/Municipality
First Name
Barangay
____________________
Middle Name
Region
Province
City/Municipality
40b Landline #
40c Mobile #
41 Date Completed
____/____/___
Department
40a Address
_________________ _________ _________________ _______________ ___________ _______
Number & Street Name
39d Mobile #
Zip Code
Barangay
Zip Code
mm dd
yyyy
DEPARTMENT OF HEALTH
Integrated Chronic Non-Communicable Disease Registry System
No.
1
2
Field Name
National Registry No.
Instruction
This is a system-generated number assigned by the NEISS software. Once the injury report is encoded into the system, copy the systemgenerated number and write on the blank area.
Write the name of the Hospital who is submitting the report.
3
4
5
6
7
Sex
Check the appropriate box for the sex of the injured by birth.
9
10
Civil Status
Mothers Maiden Name
11
11a
12
12a
12b
13
14
15
16
17
18
Permanent Address
Temporary Address
Landline #
Mobile #
Email Address
Birth Date
If Date of Birth is not available
Place of Birth
Religion
Nationality
Race
Check the appropriate box for the civil status of the injured. Not legally separated still to be considered as Married
Write the mothers name of the patient before marriage. The full middle name must be entered. If there is no middle name, write
N/A.
Write the patients permanent address - House No. and Street, Barangay, Municipality/City and Province
Write the patients temporary address - House No. and Street, Barangay, Municipality/City and Province
Write the patients contact details such as landline number, mobile number and email address.
19
20
Ethnicity
Highest Educational Attainment
21
22
23
23a
Occupation
Company
PhilHealth #
Common Reference #
24
24a-24d
25
26
27
28
Write the hospital-based issued I.D. or number to uniquely identify the patient.
Write the hospital-based issued registry number to uniquely identify the patient.
Write the hospital-based issued case number uniquely identify each case or incidence.
Check the button for the corresponding type of patient the victim is.
Write the patients Last name, First name and Middle name in the appropriate spaces provided.
Write the date of birth of the patient in the format mm/dd/yyyy (eg. July 1, 1970 should be entered as 07/01/1970 )
If date of birth cannot be provided then enter in the space provided the age of the patient in years or months or days.
Write the Province and the City/Municipality where the patient was born.
Write the patients religion.
Write the patients nationality.
Write the race of the person which describes the skin color, i.e. American (Red Skin), Caucasian (White Skin), Ethiopian (Black Skin),
Malay (Brown Skin), Mongolian (Yellow Skin)
Write the ethnicity of the patient, e.g. Asian, Indian, Pacific Islander, or others
Write the highest educational attainment of the patient whether he is elementary, high school, vocational, college, post graduate, or
others.
Check the appropriate box for the occupation of the injured.
Write the name of the company where the injured is working.
Write the PhilHealth Number of the patient if he is a member or a dependent.
Write the Unified Multi-Purpose ID Common Reference No. if the patient has any. (UMID CRN can be found in the upgraded,
present government IDs such as the SSS, GSIS and Philippine Health Insurance Corp. UMID-CRN is the primary identifier of an
individual transacting business or availing of services from any government agency.)
Write the name of the person that may be contacted should any emergency may happen to the patient.
Write the address and other contact details such as landline number, mobile number and the email address.
Write the date of the patients Consultation/Admission
Write the patients chief complaint
Check the appropriate box corresponding to the patients History of Vision Loss.
Check the appropriate box corresponding to the Degree of Vision Loss the patient has. Please refer to the chart produced by the World
Health Organization's Programme for Prevention of Blindness illustrates the different categories of vision impairment:
Category of Visual
Impairment
1
4
5
9
3/60
1/20 (0.05)
20/400
1/60 (finger-counting at 1 metre)
1/50 (0.02)
5/300 (12/1200)
No light perception
Undetermined or unspecified
Adapted from International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Geneva, World Health
Organization, 1992
Categories of visual impairment 1 and 2 are referred to as "low vision"; categories 3, 4, and 5 as "blindness"; and category 9 as
"unqualified visual loss." If the extent of the visual field is taken into account, patients with a field no greater than 10 degrees but greater
than 5 degrees around central fixation should be placed in category 3, and patients with a field no greater than 5 degrees around central
fixation should be placed in category 4, even if visual acuity is not impaired.
29
30a
30b
Check for the appropriate box whether the patient had already gone an eye surgery previously.
Check the appropriate box for the type/s of Refractive Error the patient has.
Check the appropriate box for the type/s of eye disorders the patient has.
DEPARTMENT OF HEALTH
Integrated Chronic Non-Communicable Disease Registry System
30c
31
32
33
Underlying Causes
Prognosis of Vision Loss:
Prosthetic Device
Type of Cataract
34
35
35a
35b
36
37
38
39
39a
39b
39c
39d
39e
40
40a
40b
40c
40d
41
Date Completed
The position title /designation of the personnel completing the form must be entered on this portion including the address and contact
details (landline no., mobile no. and email address).
Write the date when the form was accomplished must be entered on this portion.