Medical Assistance - Applicant Profiling

What is Medical Assistance?

Medical Assistance provides financial support to qualified individuals and families who need help with medical-related expenses.

The assistance may help with medical treatment and medicines.

Medical Assistance Requirements

Please prepare the following requirements before proceeding with your application.

Required Documents

Barangay ID / Proof of Residency
Official document confirming that you are a bonafide resident of the barangay.

Document Guidelines

Documents must be clear, complete, and fully readable.
Accepted file formats: PDF, JPG, JPEG, PNG.
Make sure all required documents are prepared before submitting.

Medical Assistance Application Form

Please complete all required application details below.

Applied before? Log in first so this application is added to your existing account.

1. Applicant Details

First Name

Middle Name

Last Name

Date of Birth

Age

Sex

Civil Status

Barangay Residency

Contact Number

Complete Address

Email Address

Your login details and a link to set your own password will be sent here.

2. Medical Profiling Details

Please read the 7 questions below carefully and answer each one honestly: select YES or NO.

1) Has your doctor ever said that you have a heart condition OR high blood pressure?

2) Do you feel pain in your chest at rest, during your daily activities of living, OR when you do physical activity?

3) Do you lose balance because of dizziness OR have you lost consciousness in the last 12 months? Please answer NO if your dizziness was associated with over-breathing (including during vigorous exercise).

4) Have you ever been diagnosed with another chronic medical condition (other than heart disease or high blood pressure)?

5) Are you currently taking prescribed medications for a chronic medical condition?

6) Do you currently have (or have had within the past 12 months) a bone, joint, or soft tissue (muscle, ligament, or tendon) problem that could be made worse by becoming more physically active? Please answer NO if you had a problem in the past, but it does not limit your current ability to be physically active.

7) Has your doctor ever said that you should only do medically supervised physical activity?

Follow-up Questions About Your Medical Condition(s)

1. Do you have Arthritis, Osteoporosis, or Back Problems?

1a. Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)

1b. Do you have joint problems causing pain, a recent fracture or fracture caused by osteoporosis or cancer, displaced vertebra (e.g., spondylolisthesis), and/or spondylolysis/pars defect (a crack in the bony ring on the back of the spinal column)?

1c. Have you had steroid injections or taken steroid tablets regularly for more than 3 months?

2. Do you currently have Cancer of any kind?

2a. Does your cancer diagnosis include any of the following types: lung/bronchogenic, multiple myeloma (cancer of plasma cells), head, and/or neck?

2b. Are you currently receiving cancer therapy (such as chemotherapy or radiotherapy)?

3. Do you have a Heart or Cardiovascular Condition? This Includes Coronary Artery Disease, Heart Failure, Diagnosed Abnormality of Heart Rhythm

3a. Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)

3b. Do you have an irregular heart beat that requires medical management? (e.g., atrial fibrillation, premature ventricular contraction)

3c. Do you have chronic heart failure?

3d. Do you have diagnosed coronary artery (cardiovascular) disease and have not participated in regular physical activity in the last 2 months?

4. Do you currently have High Blood Pressure?

4a. Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)

4b. Do you have a resting blood pressure equal to or greater than 160/90 mmHg with or without medication? (Answer YES if you do not know your resting blood pressure)

5. Do you have any Metabolic Conditions? This Includes Type 1 Diabetes, Type 2 Diabetes, Pre-Diabetes

5a. Do you often have difficulty controlling your blood sugar levels with foods, medications, or other physician-prescribed therapies?

5b. Do you often suffer from signs and symptoms of low blood sugar (hypoglycemia) following exercise and/or during activities of daily living? Signs of hypoglycemia may include shakiness, nervousness, unusual irritability, abnormal sweating, dizziness or light-headedness, mental confusion, difficulty speaking, weakness, or sleepiness.

5c. Do you have any signs or symptoms of diabetes complications such as heart or vascular disease and/or complications affecting your eyes, kidneys, OR the sensation in your toes and feet?

5d. Do you have other metabolic conditions (such as current pregnancy-related diabetes, chronic kidney disease, or liver problems)?

5e. Are you planning to engage in what for you is unusually high (or vigorous) intensity exercise in the near future?

6. Do you have any Mental Health Problems or Learning Difficulties? This includes Alzheimer's, Dementia, Depression, Anxiety Disorder, Eating Disorder, Psychotic Disorder, Intellectual Disability, Down Syndrome

6a. Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)

6b. Do you have Down Syndrome AND back problems affecting nerves or muscles?

7. Do you have a Respiratory Disease? This includes Chronic Obstructive Pulmonary Disease, Asthma, Pulmonary High Blood Pressure

7a. Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)

7b. Has your doctor ever said your blood oxygen level is low at rest or during exercise and/or that you require supplemental oxygen therapy?

7c. If asthmatic, do you currently have symptoms of chest tightness, wheezing, laboured breathing, consistent cough (more than 2 days/week), or have you used your rescue medication more than twice in the last week?

7d. Has your doctor ever said you have high blood pressure in the blood vessels of your lungs?

8. Do you have a Spinal Cord Injury? This includes Tetraplegia and Paraplegia

8a. Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)

8b. Do you commonly exhibit low resting blood pressure significant enough to cause dizziness, light-headedness, and/or fainting?

8c. Has your physician indicated that you exhibit sudden bouts of high blood pressure (known as Autonomic Dysreflexia)?

9. Have you had a Stroke? This includes Transient Ischemic Attack (TIA) or Cerebrovascular Event

9a. Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)

9b. Do you have any impairment in walking or mobility?

9c. Have you experienced a stroke or impairment in nerves or muscles in the past 6 months?

10. Do you have any other medical condition not listed above or do you have two or more medical conditions?

10a. Have you experienced a blackout, fainted, or lost consciousness as a result of a head injury within the last 12 months OR have you had a diagnosed concussion within the last 12 months?

10b. Do you have a medical condition that is not listed (such as epilepsy, neurological conditions, kidney problems)?

10c. Do you currently live with two or more medical conditions?

Medical Conditions / Diagnosis

Medical Assistance Needed

3. Upload Required Documents

Barangay ID / Proof of Residency

Accepted formats: PDF, JPG, JPEG, or PNG only.

Doctor's Prescription

Upload a clear photo or scan of the prescription. Accepted formats: PDF, JPG, JPEG, or PNG only.

Before submitting: Please verify that all information is correct and that all required documents are attached.

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