PHILIPPINE HEALTH AGENDA - FIRST 100 DAYS

TSEKAP WEEKLY REPORT

NDP:
PERIOD COVERED
MUNICIPALITY:
CATCHMENT: FORM WEEKLY REPORTING FORM
BARANGAY: July 26-August 1,2017
No. of HOUSEHOLD PROFILED:

NEWBORN INFANT CHILD ADOLESCENT

20-49 yrs old 50-59 yrs old 60 yrs and Above SUBTOTAL
0-28 days 29 days - 11 mos 1-5 yrs old 6-9 yrs old 10-19 yrs old
BASIC HEALTH SERVICES F F
GRAND TOTAL
M F M F M F M F M M M F M F M F
Pregnant Post Partum Non-Pregnant Pregnant Post Partum Non-Pregnant
NUMBER OF PATIENTS ASSESSED
PHYSICAL EXAMINATION
Blood Pressure
Weight Measurement
Obese
Undernutrition
Height Measurement
Stunted
LABORATORY EXAMINATION
Blood Typing
Complete Blood Count
Urinalysis
Fasting Blood Sugar
Stool Examination
FAMILY PLANNING SERVICES
Counseling
Commodities
HEALTH EDUCATION AND PROMOTION SERVICES
OTHER SERVICES
Eye Exam
Ear Exam
Oral Services
SUBTOTAL
GRAND TOTAL
TOTAL NO. OF CLIENTS PROVIDED WITH AT LEAST 3 SERVICES
(BASED ON FORM 1A-1H)
CASES REFERRED (specify)

DRUG REHABILITATION SERVICES

Screening
Counseling
Drug Testing
Referral
TOTAL DRUG REHABILITATION SERVICES
 PHILIPPINE HEALTH AGENDA - FIRST 100 DAYS
RECORDING FORM

TSEKAP WEEK NHTS No.

Province
July 26-August Mun/City
1,2017
Brgy

Date Name of NHTS Member and Dependents Relation

No. Visited/Profiled
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
DA - FIRST 100 DAYS
FORM

SOUTHERN LEYTE
LIBAGON

PhilHealth
Birthday Age Sex Member
 FORM
1
HOUSEHOLD PROFILE

LEYTE
ON

Remarks
 PHILIPPINE HEALTH AGENDA - FIRST 100 DAYS

TSEKAP WEEKLY REPORT

NDP:
PERIOD COVERED
MUNICIPALITY:
CATCHMENT: FORM WEEKLY REPORTING FORM
BARANGAY: July 26- August 1, 2017
No. of HOUSEHOLD PROFILED:

NEWBORN INFANT CHILD ADOLESCENT

20-49 yrs old 50-59 yrs old 60 yrs and Above SUBTOTAL
0-28 days 29 days - 11 mos 1-5 yrs old 6-9 yrs old 10-19 yrs old GRAND
BASIC HEALTH SERVICES
M F M F M F M F M
F
M
F
M F M F M F
TOTAL
Pregnant Post Partum Non-Pregnant Pregnant Post Partum Non-Pregnant
NUMBER OF PATIENTS ASSESSED
PHYSICAL EXAMINATION
Blood Pressure
Weight Measurement
Obese
Undernutrition
Height Measurement
Stunted
LABORATORY EXAMINATION
Blood Typing
Complete Blood Count
Urinalysis
Fasting Blood Sugar
Stool Examination
FAMILY PLANNING SERVICES
Counseling
Commodities
HEALTH EDUCATION AND PROMOTION SERVICES
OTHER SERVICES
Eye Exam
Ear Exam
Oral Services
SUBTOTAL
GRAND TOTAL
TOTAL NO. OF CLIENTS PROVIDED WITH AT LEAST 3 SERVICES (BASED
ON FORM 1A-1H)
CASES REFERRED (specify)

DRUG REHABILITATION SERVICES

Screening
Counseling
Drug Testing
Referral
TOTAL DRUG REHABILITATION SERVICES
 PHILIPPINE HEALTH AGENDA - FIRST 100 DAYS FORM
RECORDING FORM 1
HOUSEHOLD PROFILE

TSEKAP WEEK NHTS No.

Province SOUTHERN LEYTE

July 26-August Mun/City LIBAGON
1,2017
Brgy

Date PhilHealth
Visited/Profiled Name of NHTS Member and Dependents Relation Birthday Age Sex Member Remarks