Managing and Using Information

Clinic Client Card

Date of Visit: ______________________________

Name of Client: ______________________________

Name of Husband: ______________________________

Address: ______________________________

(For Armed Forces) Rank:______________________________

Unit: ______________________________

II.

General Condition:__________________________________

Last Menstrual Period:________________________

Blood Pressure: _____________________________

Weight:_______________________________________

III.	To be filled out before giving pill, ask and notice the following:
		Yes	No
	1. Blood pressure more than 150/100
	2. Skin or eyes appear yellowish
	3. Lump in breast
	4. Swollen or throbbing varices
	5. Heavy or frequent menses
	6. Difficult breathing
	7. Frequent headache

	Explanation: Put X mark in proper column. For questions 1-4, also conduct examination. If all answers are "NO", patient can be given pill by midwife. If there is a "YES" answer, patient should be examined by a physician before being provided with pills.

IV.	Internal Examination:
	Position of Uterus: Retro/Anteflexy
		Yes	No
	1. Sign of pregnancy
	2. Sign of inflammation
	3. Tumor
	Explanation: Put X mark in proper column. If all answers are "NO", IUD may be inserted.

IV.	Contraceptive Given
		Yes	No
	Difficulty in insertion

1. IUD - Type of IUD: ______________________________

2. Pill - Total number of strips: __________________

3. Condom

4. Vaginal cream/tablet

5. Male sterilization

6. Female sterilization

7. Injectable

8. Implant ________________________________

VI. Return Visit: ___________________________________________

VII. Additional Remarks: ____________________________________________________________

________________________________________________________________________________

Signature: ___________________________________