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PREGNANT WOMEN

BARANGAY:___________________________________________
NAME OF CHT PARTNER:_________________________________

NAME AGE OUTCOME


NEWBORN (0-29 DAYS)

BARANGAY:___________________________________________
NAME OF CHT PARTNER:_________________________________

NAME AGE BIRTHDAY


UNDER FIVE CHILDREN (30 DAYS-BELOW 5 YRS OLD)

BARANGAY:___________________________________________
NAME OF CHT PARTNER:_________________________________

NAME AGE BIRTHDAY


SENIOR CITIZENS

BARANGAY:___________________________________________
NAME OF CHT PARTNER:_________________________________

NAME AGE BIRTHDAY


PERSONS WITH DISABILITY

BARANGAY:___________________________________________
NAME OF CHT PARTNER:_________________________________

NAME AGE TYPE OF DISABILITY


FAMILY PLANNING

BARANGAY:___________________________________________
NAME OF CHT PARTNER:_________________________________

NAME AGE METHOD USED


FAMILY WITH SANITARY TOILET

BARANGAY:___________________________________________
NAME OF CHT PARTNER:_________________________________

WITH SANITARY TOILET WITHOUT SANITARY TOILET


NAME OF HEAD OF THE FAMILY NAME OF HEAD OF THE FAMILY
PATIENTS WITH TB

BARANGAY:___________________________________________
NAME OF CHT PARTNER:_________________________________

NAME AGE DATE STARTED TREATMENT


PATIENTS WITH HIGH BLOOD

BARANGAY:___________________________________________
NAME OF CHT PARTNER:_________________________________

NAME AGE
PATIENTS WITH DIABETES

BARANGAY:___________________________________________
NAME OF CHT PARTNER:_________________________________

NAME AGE
CHT MEETING ATTENDANCE

DATE NAME BARANGAY SIGNATURE

CHT MEETING ATTENDANCE

DATE NAME BARANGAY SIGNATURE