UNIFIED INTAKE SHEET

ANNEX B

PhilHealth Identification No.: Hospital No.:________________

Date of Intake/Interview (Petsa ng Panayam): _______________________
Time of Interview (Oras ng Panayam): ____________________
Name of Informant (Pangalan ng Impormante): ____________________________________________ Relation to Patient (Relasyon sa Pasyente): _______________
________________________________________________________________________ ________________________________________
Address (Tirahan) Contact Number (Telepono Bilang)
I. IDENTIFYING INFORMATION (Impormasyon ng Pagkakakilanlan)
Client's Name ______________________________________________________________________________________________ ___________ / _____________
(Pangalan ng Pasyente) Last Name(Apelyido) First Name (Pangalan) Middle Name (Gitnang Pangalan) Ext. (Sr. Jr.) Sex(Seks)
_________________________________________________________/ __________/ ___________________________________________________________________
Date of Birth/Petsa ng Kapanganakan (dd/mm//yyyy) Age (Edad) Place of Birth (Lugar ng Kapanganakan)
Permanent Address/Permanenteng Tirahan :_____________________________________________________________________________________________________
Street Number, Barangay, City/Municipality, District, Province, Region
Present Address/Kasalukuyang Tirahan:_________________________________________________________________________________________________________
Street Number, Barangay, City/Municipality, District, Province, Region
Civil Status: Single Married Widow/Widower Separated with Common Law Partner Others
Religion (Relihiyon):_______________________________________________Nationality (Nasyonalidad):_________________________________
Highest Educational Attainment/Pinaka-Mataas na Edukasyon: Post Grad College High School Elementary None
Occupation (Trabaho):___________________________________________________ Monthly Income (Kinikita Kada Buwan):_________________________________
II. FAMILY COMPOSITION (Komposisyon ng Pamilya)
(Kompusisyon ng Pamilya)
Birthdate Relation to
Last Name/ 1st /Middle YY/MM/DD Sex Civil Status Patient Highest Educational Attainment Occupation Monthly Income

1
2
3
4
5
6
7
8
9
10
Other Source/s of family Income (Ibang Pinagkakakkitaan ng Pamilya): __________________
Total Family Income (Kabuuang Kita ng Pamilya): __________________________
III. LIST OF EXPENSES (Talaan ng mga Gastusin)
House/Lot : Owned/Sarili Rented/InuupahanHow Much/Magkano: Food (Pagkain): Education (Edukasyon):
Light Source/Pinagmumulan ng Ilaw: Electricity Kerosene Candle Transportation (Pamasahe): Clothing (Kasuotan):
Water Source/Pinagmumulan ng Tubig: Owned Public Artesian Well Medical (Medikal): Househelp (Kasambahay):
Insurance Premium: Others (Iba pa):
IV. PROBLEM PRESENTED (Problemang Idinudulog):
Health Condition of Patient (specify) Economic resources (specify) Housing (specify)
Food/Nutrition (specify) Employment (specify) Other (specify)

*AKO AY NAGPAPATUNAY NA ANG IMPORMASYONG NAKASULAT SA IBABAW AY TOTOO AT TAMA

_____________________________________________________ Thumb Mark

Name and Signature of the Client/Pangalan at Lagda ng Kliyente
V. SOCIAL WORKER'S ASSESSMENT (Pagtatasa ng Social Worker):
___________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
VI. RECOMMENDATIONS (Rekomendasyon):
TYPE OF ASSISTANCE AMOUNT OF ASSISTANCE MODE OF ASSISTANCE FUND SOURCE

Reviewed and
Interviewed by ____________________________________________ Approved by: ____________________________________
Signature over Name of Medical Social Worker Signature over Name
 UNIFIED INTAKE SHEET
ANNEX B
PhilHealth Identification No.: Hospital No.:________________
Date of Intake/Interview (Petsa ng Panayam): Time of Interview (Oras ng Panayam):
_______________________ ____________________
Name of Informant (Pangalan ng Impormante): ____________________________________________ Relation to Patient (Relasyon sa Pasyente): __________
________________________________________________________________________ ________________________________________
Address (Tirahan) Contact Number (Telepono Bilang)
I. IDENTIFYING INFORMATION (Impormasyon ng Pagkakakilanlan)
Client's Name ______________________________________________________________________________________________ ___________ / _____________
(Pangalan ng Pasyente) Last Name(Apelyido) First Name (Pangalan) Middle Name (Gitnang Pangalan) Ext. (Sr. Jr.) Sex(Seks)
_________________________________________________________/ __________ / ___________________________________________________________________
Date of Birth/Petsa ng Kapanganakan (dd/mm//yyyy) Age (Edad) Place of Birth (Lugar ng Kapanganakan)
Permanent Address/Permanenteng Tirahan :____________________________________________________________________________________________
Street Number, Barangay, City/Municipality, District, Province, Region
Present Address/Kasalukuyang Tirahan:________________________________________________________________________________________________
Street Number, Barangay, City/Municipality, District, Province, Region
Civil Status: Single Married Widow/Widower Separated with Common Law Partner Others
Religion (Relihiyon):_______________________________________________
Nationality (Nasyonalidad):_________________________________
Highest Educational Attainment/Pinaka-Mataas na Edukasyon: Post Grad College High School Elementary None
Occupation (Trabaho):___________________________________________________
Monthly Income (Kinikita Kada Buwan):______________________________
II. FAMILY COMPOSITION (Komposisyon ng Pamilya)
(Kompusisyon ng Pamilya)
Birthdate
Last Name/ 1st /Middle YY/MM/DD Sex Civil Status Relation
Patient
to
Highest Educational Attainment Occupation Monthly Income

1
2
3
4
5
6
7
8
9
10
Other Source/s of family Income (Ibang Pinagkakakkitaan ng Pamilya): __________________
Total Family Income (Kabuuang Kita ng Pamilya): ________________________
III. LIST OF EXPENSES (Talaan ng mga Gastusin)
House/Lot : Owned/Sarili Rented/Inuupahan
How Much/Magkano: Food (Pagkain): Education (Edukasyon):
Light Source/Pinagmumulan ng Ilaw: Electricity Kerosene Candle Transportation (Pamasahe): Clothing (Kasuotan):
Water Source/Pinagmumulan ng Tubig: Owned Public Artesian Well Medical (Medikal): Househelp (Kasambahay):
Insurance Premium: Others (Iba pa):
IV. PROBLEM PRESENTED (Problemang Idinudulog):
Health Condition of Patient (specify) Economic resources (specify) Housing (specify)
Food/Nutrition (specify) Employment (specify) Other (specify)

*AKO AY NAGPAPATUNAY NA ANG IMPORMASYONG NAKASULAT SA IBABAW AY TOTOO AT TAMA

_____________________________________________________ Thumb Mark

Name and Signature of the Client/Pangalan at Lagda ng Kliyente
V. SOCIAL WORKER'S ASSESSMENT (Pagtatasa ng Social Worker):
___________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
VI. RECOMMENDATIONS (Rekomendasyon):
TYPE OF ASSISTANCE AMOUNT OF ASSISTANCE MODE OF ASSISTANCE FUND SOURCE

Reviewed and
Interviewed by ____________________________________________
Approved by:
____________________________________
Signature over Name of Medical Social Worker Signature over Name