SIDE A FAMILY PLANNING (FP) FORM 1 ver. 3.

0
FAMILY PLANNING CLIENT ASSESSMENT RECORD CLIENT ID: _____________________________________
Instructions for Physicians, Nurses and Midwives: Make sure that the client is not pregnant by 01-025538015-5
PHILHEALTH NO.: _______________________________
using the questions listed in SIDE B. Completely fill out or check the required information. Refer NHTS?: oYes oNo Pantawid Pamilya Pilipino Program(4Ps): oYes oNo
accordingly for any abnormal history/findings for further medical evaluation
NAME OF CLIENT: Gomez Ana C.
______________________________________________________ __05
__ /__05
__ /__1981 35
__ __ __ _____ Factory Worker
___________________ _______________
Last Name Given Name MI Date of Birth Age Educ. Attain. Occupation
89-B Rizal Ave. Brgy. 845 Manila 09178096321 Married Roman Catholic
ADDRESS: ____________________________________________________________ __________________ ________________ _____________________
No. Street Barangay Municipality/City Province Contact Number Civil Status Religion
Gomez Antonio L. 37 Factory Worker
NAME OF SPOUSE: ____________________________________________________________ __12
__ /__06__ /__1978
__ __ __ ________ ____________________
Last Name Given Name MI Date of Birth Age Occupation
3
NO. OF LIVING CHILDREN: _________ PLAN TO HAVE MORE CHILDREN? o Yes o No AVERAGE MONTHLY INCOME: _________________________
P30,000
Type of Client
o New Acceptor Reason for FP: o spacing o limiting o others___________ Method currently used (for Changing Method):
o Current User o COC  IUD o BOM/CMM o LAM
o Changing Method Reason: o medical condition o side-effects _____________ o POP o Interval o BBT o others
o Changing Clinic o Injectable o Post-Partum o STM specify: _______
o Dropout/ Restart o Implant o Condom o SDM
I. MEDICAL HISTORY IV. RISKS FOR VIOLENCE AGAINST WOMEN (VAW)
Does the client have any of the following? unpleasant relationship with partner oYes oNo
 severe headaches / migraine oYes oNo partner does not approve of the visit to FP clinic oYes oNo
history of stroke / heart attack / hypertension oYes oNo history of domestic violence or VAW oYes oNo
non-traumatic hematoma / frequent bruising or gum bleeding oYes oNo Referred to: o DSWD
current or history of breast cancer / breast mass oYes oNo o WCPU
severe chest pain oYes oNo o NGOs
cough for more than 14 days oYes oNo o Others (Specify: ___________________________)
jaundice oYes oNo V. PHYSICAL EXAMINATION
unexplained vaginal bleeding oYes oNo 50
Weight: _________ kg 110/70 mmHg
Blood pressure: _______
abnormal vaginal discharge oYes oNo 1.7
Height: _________ m 82
Pulse rate: _______ /min
intake of phenobarbital (anti-seizure) or rifampicin (anti-TB) oYes oNo SKIN: EXTREMITIES
Is the client a SMOKER? oYes oNo o normal o normal
With Disability? oYes oNo o pale o edema
(if YES please specify: _______________________________________) o yellowish o varicosities
II. OBSTETRICAL HISTORY o hematoma PELVIC EXAMINATION
4
Number of pregnancies: G________ 3
P ________ CONJUNCTIVA: (For IUD Acceptors)
3 Full term _____
_____ 0 Premature o normal o normal
1 Abortion _____
_____ 3 Living children o pale o mass
Date of last delivery __10__ /__31
__ /__ 2014
__ __ __ o yellowish o abnormal discharge
Type of last delivery oVaginal oCesarean Section NECK: o cervical abnormalities
Last menstrual period __04__ /__25__ /__2016
__ __ __ o normal o warts
Previous menstrual period __ 03__ /__23
__ /__2016
__ __ __ o neck mass o polyp or cyst
Menstrual flow : o enlarged lymph nodes o inflammation or erosion
oscanty (1-2 pads per day) BREAST: o bloody discharge
omoderate (3-5 pads per day) o normal o cervical consistency
oheavy (>5 per pads day) o mass o firm o soft
o Dysmenorrhea o nipple discharge o cervical tenderness
o Hydatidiform mole (within the last 12 months) ABDOMEN o adnexal mass / tenderness
o History of ectopic pregnancy o normal o uterine position:
III. RISKS FOR SEXUALLY TRANSMITTED INFECTIONS o abdominal mass o mid
Does the client or the client’s partner have any of the following? o varicosities o anteflexed
abnormal discharge from the genital area oYes oNo o retroflexed
if "YES" please indicate if from: oVagina oPenis o uterine depth: _______
7 cm
sores or ulcers in the genital area oYes oNo ACKNOWLEDGEMENT:
pain or burning sensation in the genital area oYes oNo This is to certify that the Physician/Nurse/Midwife of the clinic has fully
history of treatment for sexually transmitted oYes oNo explained to me the different methods available in family planning and I
infections IUD
freely choose the ____________________________ method.
HIV / AIDS / Pelvic inflammatory disease oYes oNo 05/01/2016
_____________________________ _____________________
Client Signature Date
For WRA below 18 yrs. Old:
Implant = Progestin subdermal implant; IUD = Intrauterine device; BTL = Bilateral tubal ligation; NSV = No-scalpel I hereby consent _______________________ to accept the Family Planning
vasectomy; COC = Combined oral contraceptives; POP = Progestin only pills; LAM = Lactational amenorrhea method; method.
SDM = Standard days method; BBT = Basal body temperature; BOM = Billings ovulation method; CMM = Cervical
mucus method; STM = Symptothermal method _____________________________ _____________________
Parent/Guardian Signature Date
SIDE B FP FORM 1
FAMILY PLANNING CLIENT ASSESSMENT RECORD
NAME AND DATE OF
MEDICAL FINDINGS
DATE OF VISIT SIGNATURE OF FOLLOW-UP
(Medical observation, complaints/ complication, service rendered/ procedures, laboratory METHOD ACCEPTED
(MM/DD/YYYY) SERVICE VISIT
examination, treatment and referrals)
PROVIDER (MM/DD/YYYY)

05/01/2016 Patient voluntarily sought family planning services in the clinic. IUD 05/01/2017
After being informed of all the advantages and disadvantages of
all available family planning method, she decided to avail the IUD.
Patient is already on her 6th day of menstrual cycle. KAY CLARICE T. TAN
Intra uterine device was inserted after careful assessment.

How to be Reasonably Sure a Client is Not Pregnant

1. Did you have a baby less than six (6) months ago, are you fully or nearly-fully breastfeeding, and have you o Yes o No
had no menstrual period since then?
2. Have you abstained from sexual intercourse since your last menstrual period or delivery? o Yes o No
3. Have you had a baby in the last four (4) weeks? o Yes o No
4. Did your last menstrual period start within the past seven (7) days? o Yes o No
5. Have you had a miscarriage or abortion in the last seven (7) days? o Yes o No
6. Have you been using a reliable contraceptive method consistently and correctly? o Yes o No
 If the client answered YES to at least one of the questions and she is free of signs or symptoms of pregnancy, provide client with desired method.
 If the client answered NO to all of the questions, pregnancy cannot be ruled out. The client should await menses or use a pregnancy test.