Chronic Obstructive Pulmonary Disease Registry Form
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4DEPARTMENT OF HEALTH
Integrated Chronic Non-Communicable Disease Registry System
1 National Registry No.
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Note: Please put N/A for Not Applicable fields. Kindly refer to the instruction on how to fill up the form at the back.
GENERAL DATA
2 Name of Reporting Health Facility
*3 Hospital Patient ID No.
*4 Hospital Registry No.
*5 Hospital Case No.
*6 Type of Patient
OPD
In Patient
*7 Name of Patient
*8 Sex
*9 Civil Status
Female
Single
Married
Male
Widow/er
Separated
____________________ __________________ _________________
Co-Habitation
Annulled Divorced
Last Name
First Name
Middle Name
*10 Mother’s Maiden Name ________________________ ______________________ _______________________
Last Name
First Name
Middle Name
*11 Permanent Address
12 Landline #
____________________ _________ ___________________ __________________ _________________
__________
Number & Street Name
Region
Province
City/Municipality
Barangay
Zip Code
12a Mobile #
11a Temporary Address
12b Email Address
____________________ _________ ___________________ __________________ _________________
__________
Number & Street Name
Region
Province
City/Municipality
Barangay
Zip Code
13 Birth Date
14 If Date of Birth is not available
*15 Place of Birth
*16 Religion
18 Race
(Province,City/Municipality)
*17 Nationality
19 Ethnicity
____/____/____
____Yrs ____ Mos ____ Days
mm
dd
yyyy
*20 Highest Educational Attainment
*21 Occupation
22 Company
23 PhilHealth #
23a
Common Reference #
24 Contact Person
________________, _________________, _________________
24b Landline #
24d Email Address
(in case of emergency)
Last Name
First Name
Middle Name
24a Address
24c Mobile #
_________________ _________ _________________ ______________ _______________ ______
Number & Street Name
Region
Province
City/Municipality
Barangay
Zip Code
PATIENT HISTORY
*25 Smoking
*27 Occupational Exposure
*28 Pulmonary Infections
Less than/Equal to 1 pack
Cement Dust
TB
Others, specify _______________
consumed per day
Cotton
More than 1 pack consumed/day
Grains
*29 Indoor Air Pollution
Metal
Age started Smoking: ___________
Type of Indoor Air Pollutant
Paper Mill
Number of Years Smoking: _______
__________________________
Silica
*26 Second Hand Smoke (SHS)
Others, specify ________________
With Exposure to SHS
*30 Outdoor Air Pollution
Type of Outdoor Air Pollutant
Number of Years: ______
____________________________
__________________________
COPD DATA
*31 Type of COPD, specify __________________________________
*32 Referred From
33 Name of Referring Health Facility
34 Reason for Referral
*35 Date of Consultation/Admission
____/____/_____
*36 Date of Diagnos ____/____/_____
mm
dd
yyyy
mm dd
yyyy
*37 Sign/Symptoms Chest Tightness
Chronic Cough
Clubbing of the Fingers
Cyanosis
Dyspnea
Frequent Chest Infections
Hemoptysis
Increase in Sputum Production
Wheezing
Others, specify________________________________________________________________________
*38 Treatment Bronchodilator
Corticosteroids
Combination Corticosceroids – long Acting Beta 2-agonis
Mucolytics
Antibiotics
Others, specify ______________________________________
*39 Status of Severity At Risk
Mild COPD (FEV.>=80%)
Moderate COPD (FEV. >=50% but <80% predicted)
Severe COPD (FEV.>=30% but 50% predicted)
Very Severe COPD (FEV. <50% with Respiratory Failure or Clinical Signs of Right Heart Failure)
Unknown
*40 Final Diagnosis: POST BRONCHODILATOR FEV/FVC < 70% ______________(Spirometry)
41 Final Diagnosis: ICD-1O Code
*42 Patient Status Recovered Improved Unimproved Died
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