INA BIRTHING AND FAMILY PLANNING CLINIC

Unit 2 & 3 NagaVille Bldg, CBD II, Trianggulo, Naga City Camarines Sur 4400
BIRTHING CLINIC
FACE
SHEET

PHILHEALTH NUMBER: _______________________

MAIDEN NAME Surname
First
Birthdate
Address
Religion
Contact Number

Occupation

Relationship

Address

Admitting Diagnosis
G__P__ (_____) Pregnancy Uteri; _____weeks age of gestation; cephalic; in
labor
Admitting NOD/MOD

Time
AM______
PM______
Date Discharged:
Time
AM______

FINAL DIAGNOSIS
G__P__ (_____) _____weeks age of gestation; delivered via NSD; live birth
Baby ______.

PM______
Condition upon discharged
[ ] recovered
[ ]died
[ ] improved
[ ]autopsied
[ ]unimproved
FOR BIRTH CERTIFICATE
Name of Child
Weight at Birth
Name of Father
Nationality

Age

Nationality

Name of Next kin

Contact Number
Date Admitted:

Middle Name

Disposition
[ ] Discharged
autopsied
[ ]Transferred out
[ ]HAMA

Sex

(include Middle Name)

Date of Delivery:
[ ]not
Time of Delivery

Type of Birth
Age

Religion

Residence
Birth Attendant

Date and Place of Marriage

Informant
Residence

Relationship to the child

Birth Order
Occupation

Total no. of children born alive:_______ Total no. of children still living including this birth:______ Total no. of children born alive but are
now dead:______________

CONSENT TO CARE
I hereby authorized the staff of the INA BIRTHING & FAMILY PLANNING CLINIC to perform the
treatment and procedures deemed necessary for my care. I also give authorization for the
Birthing Clinic to supply information from my medical records to my insurance carrier/and or the
attorney.

INA BIRTHING AND FAMILY PLANNING CLINIC

Unit 2 & 3 NagaVille Bldg, CBD II, Trianggulo, Naga City Camarines Sur 4400
_____________________________
______________________________________
Witness
Signature over printed
name of patient
BUSINESS OFFICE CLEARANCE
TO HEAD NURSE
Patient is cleared of financial obligation and maybe discharged after properly clearance from the
Clinic.
Amount paid:______________________
O.R No:___________________________
Date:_____________________________
_________________________
_____________________
Birthing Clinic Personnel
Guard on Duty
Philhealth Identification Number:___________________________________

PATIENTS DATA SHEET

Name:______________________________________________________________
Status:____
MAIDEN NAME(Last Name)

(First Name)

Age:_____

(Middle Name)

Address:_____________________________________________________________
Religion:______________________
(No. of House)

(Street)

(Barangay)

(Town)

(Province)

Date of Birth:_____________________________________________ Birth

Place:________________________________
Nationality:____________________ Occupation:_________________________
Employer:________________________
Date Admitted:___________________ Time Admitted:____________________ No. of Times
Admitted:______________
Ward:_________________ Room No.:_________________________________ Bed
No.:__________________________
Date Discharged:___________________________________________ Time
Discharged:___________________________
Fathers Name:_____________________________________________
Address:_________________________________
Occupation:________________________________________________
Employer:_______________________________

Sex:___

Civil

INA BIRTHING AND FAMILY PLANNING CLINIC

Unit 2 & 3 NagaVille Bldg, CBD II, Trianggulo, Naga City Camarines Sur 4400
Mothers Name: ____________________________________________
Address:_________________________________
Name of Spouse:________________________________ Age: ____ Date of
Birth:__________Occupation:____________
(Last Name)

(First Name)

(Middle Name)

Religion:__________________Employer:________________________________ Address:
_________________________
Barangay
Captain:___________________________________________________________________________________
Companion:______________________________________________________________________________________
__
PERSON TO BE NOTIFIED IN CASE OF EMERGENCY:
Name:_____________________________________________________
Relationship:____________________________
Address:_________________________________________________________________________________________
__

______________________________________________
Signature over Printed Name
Midwife

_____________________________________________
Signature over Printed Name of

_____________________________________________
Signature over Printed name of Midwife
on Duty

HISTORY RECORD
NAME OF
PATIENT__________________________________________WARD_________________DATE______________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
General Data
(Upon Admission)
Date/ Time

INA BIRTHING AND FAMILY PLANNING CLINIC

Unit 2 & 3 NagaVille Bldg, CBD II, Trianggulo, Naga City Camarines Sur 4400

L
M
P
ED
C
A
O
G
BP

PR
RR

Temp

FH
FHT

Cx
Dilatati
on
BOW
Present
ation

Name_______________________________________________________________
Age_______________________
Physician_____________________________________________________________ Bed
No.___________________
CLINICAL LABORATORY FORM

INA BIRTHING AND FAMILY PLANNING CLINIC

Unit 2 & 3 NagaVille Bldg, CBD II, Trianggulo, Naga City Camarines Sur 4400

Name_______________________________________________________________
Age_______________________
Physician_____________________________________________________________ Bed
No.___________________
CONSULTATION/ REFERRAL NOTES

INA BIRTHING AND FAMILY PLANNING CLINIC

Unit 2 & 3 NagaVille Bldg, CBD II, Trianggulo, Naga City Camarines Sur 4400

Name_____________________________________________________
Age_____________________________________
Physician__________________________________________________ Bed
No.__________________________________
INFORMED CONSENT FOR PROCEDURES
I, ____________________________________________ the undersigned, a patient in room/ward ___________of
Ina Birthing and Family Planning Clinic hereby certify that I have fully understood the following
procedure/operation which was explained by my Doctor.
Date & Time
Procedure
Signature of Doctor/Midwife
Signature of
Patient
____________________ ____________________
_____________________ ___________________
____________________ ____________________
_____________________ ___________________
____________________ ____________________
_____________________ ___________________
____________________ ____________________
_____________________ ___________________
I hereby attached my signature to authorize the Medical and Hospital Staff in-charge of my care to
perform the above operation/procedure. I understand that the above operation is/are necessary for
the evaluation of my case and /or the proper care of my illness.

INA BIRTHING AND FAMILY PLANNING CLINIC

Unit 2 & 3 NagaVille Bldg, CBD II, Trianggulo, Naga City Camarines Sur 4400
__________________________________________
Signature of Patient or Thumb Mark
__________________________________________
Nearest Relative

In the Presence of:

__________________________________________
Relationship to the Patient

_____________________________________
Witness

__________________________________________
Address
CONSENT FOR REFUSAL OF PROCEDURE
Date:___________________________________
Dr./Midwife________________________________________has fully explained to me the nature, purpose risks,
and benefits of the proposed treatment, the possible alternatives thereto, and the risks and
consequences of not proceeding. I nonetheless refuse to consent to the proposed treatments.
I have been given an opportunity to ask questions, and all of my questions have been answered fully
and satisfactorily.
I hereby release the hospital, its employees and medical staff, and the attending physician from any
liability for ill affects that may result from my decision to refuse to consent to proposed treatment.
I confirm that I have read and fully under and fully understand the above and that allthe blank spaces
were completed prior to my signing.
__________________________
Patient/Relative or Guardian
__________________________
Relationship

_____________________________
Attending Physician

__________________________
Interpreter (if used)

_____________________________
Witness

PHYSICIANS ORDER
Date/ Time

INA BIRTHING AND FAMILY PLANNING CLINIC

Unit 2 & 3 NagaVille Bldg, CBD II, Trianggulo, Naga City Camarines Sur 4400

MEDICATION SHEET
Medicine

Shift
7-3
3-11
11 - 7
7-3
3-11
11 - 7

INA BIRTHING AND FAMILY PLANNING CLINIC

Unit 2 & 3 NagaVille Bldg, CBD II, Trianggulo, Naga City Camarines Sur 4400
7-3
3-11
11 - 7
7-3
3-11
11 - 7
7-3
3-11
11 - 7
7-3
3-11
11 - 7
Date

Medicine

Date

Medicine

Name_____________________________________________________
Age_____________________________________
NAME:__________________________________________________
DATE:_____________________________________
FINALDIAGNOSIS:______________________________________________________________________________
__________________________________________________________________________________________________
_________________________________________________________________________________________________
I.

MEDICATION

MEDICINES

Cefalexin
capsule

500mg

MORNING

NOON

EVENING

1 cap

1 cap

1 cap

SPECIAL
CONSIDERATIO
N
For 7 days

INA BIRTHING AND FAMILY PLANNING CLINIC

Unit 2 & 3 NagaVille Bldg, CBD II, Trianggulo, Naga City Camarines Sur 4400
Mefenamic
500mg
capsule

Acid

Ferrous Sulfate

II.

1 cap

1 cap

1 cap

For 3 days

1 cap

1 cap

1 cap

For 30 days

SPECIAL CARE INSTRUCTION

-

Exclusively breastfeed baby 6 months up to 2 years and beyond, no water and vitamins
supplement.
Burp baby every after feeding.
Apply 70% isoprophyl alcohol 2-3x a day unto babys umbilical stump.
Bath baby daily.
Expose to morning sunlight daily.
Do not apply baby powder and lotion unto babys skin to avoid skin irritation.

DATE
OF
FOLLOW
UP
UP:_______________________________________________________________________
________________________________________
Signature of Person Receiving Instruction
Attending Physician

CHECK-

________________________________

________________________________________
Name and Signature of Nurse/ Midwife
Date/
Time

BP

CR

VITAL SIGNS MONITORING SHEET

RR
Temp.
O2 Sat
CVP

Intake

Output

INA BIRTHING AND FAMILY PLANNING CLINIC

Unit 2 & 3 NagaVille Bldg, CBD II, Trianggulo, Naga City Camarines Sur 4400

Name_______________________________________________________________
Age_______________________
Physician_____________________________________________________________ Bed No.__________________

INA BIRTHING AND FAMILY PLANNING CLINIC

Unit 2 & 3 NagaVille Bldg, CBD II, Trianggulo, Naga City Camarines Sur 4400