Get Diabetes Registry Form - Unified Health Management Information ...

This guide provides clear instructions for filling out the Diabetes Registry Form online, ensuring that users can submit accurate and complete information. By following these steps, you will contribute to a comprehensive health registry.

Follow the steps to successfully complete the Diabetes Registry Form online.

1. Press the ‘Get Form’ button to access the Diabetes Registry Form and open it in your document editor.
2. Begin by entering the National Registry Number. If you do not have this information, leave it blank as it is system generated.
3. Fill in the name of the Reporting Health Facility where the patient is receiving care.
4. Enter the Hospital Patient ID Number to uniquely identify the patient.
5. Provide the Hospital Registry Number, which is designated for each patient record.
6. Indicate the Hospital Case Number that corresponds to the medical case of the patient.
7. Input the patient's Name, including Last Name, First Name, and Middle Name.
8. Select the patient's sex by checking the appropriate option: Female or Male.
9. Report the patient's civil status by selecting one of the options provided.
10. Document the Mother's Maiden Name in the designated fields.
11. Enter the patient's permanent address including Number & Street Name, Barangay, City/Municipality, and Province.
12. Fill out the patient's temporary address (if applicable) as you did for the permanent address.
13. Provide contact information including landline number, mobile number, and email address.
14. Indicate the patient's Birth Date using the format mm/dd/yyyy.
15. If the exact date of birth is not available, provide age in years, months, and days.
16. Enter Place of Birth including Province and City/Municipality.
17. Provide details regarding Religion, Nationality, Race, and Ethnicity.
18. Select the Highest Educational Attainment of the patient.
19. Document the patient's Occupation and Company if applicable.
20. Fill in the PhilHealth Number and any Common Reference Number if available.
21. In case of emergencies, provide a Contact Person's information including their address and contact details.
22. Complete the Patient History section, including information about smoking and physical activities.
23. Fill out the Diabetes Data section, specifying if the patient was referred, date of consultation, and other relevant health details.
24. For the final sections, provide information about current treatment, surgical history, and patient status.
25. Once all sections are completed, save your changes, download the form, and print or share it as necessary.

Complete the Diabetes Registry Form online today to help enhance health management systems.