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M1
FHSIS REPORT for the MONTH: ________ YEAR: _______

Name of Barangay: _______________________________
Name of BHS: _______________________________
Name of Municipality/City: _______________________________
BRGY
Name of Province: _______________________________
Projected Population of the Year: _______________________________
For submission to RHU/MHC
Section A. Family Planning Services and Deworming for Women of Reproductive Age
A1. Modern FP Unmet Need Age Total A3. Deworming Services SES Total
(Col. 1) (Col. 2) (Col. 3) (Col. 1) (Col. 2) (Col. 3)
15-19 20-49 NHTS Non-NHTS
1. No. of WRA with unmet 1. No. of women 20-49 years old given 2 doses of
need for modern FP - Total deworming drugs - Total
• NHTS
• Non-NHTS
A2. Use of FP Method Current User Acceptors Dropout Current User New Acceptors
(Beginning Month) New Acceptors Other Acceptors (Present Month) (End of Month) (Present Month)
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4) (Col. 5) (Col. 6) (Col. 7)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total
a. Female Sterilization/ BTL -Total
• NHTS
• Non-NHTS
b. Male Sterilization/ NSV-Total
• NHTS
• Non-NHTS
c. Condom - Total
• NHTS
• Non-NHTS
d. Pills - Total
• NHTS
• Non-NHTS
d.1 Pills-POP - Total
• NHTS
• Non-NHTS
d.2 Pills-COC - Total
• NHTS
• Non-NHTS
e. Injectables (DMPA/ POI) - Total
• NHTS
• Non-NHTS
f. Implant - Total
• NHTS
• Non-NHTS
g. IUD (IUD-I and IUD-PP) - Total
• NHTS
• Non-NHTS
1
A2. Use of FP Method Current User Acceptors Dropout Current User New Acceptors
(Beginning Month) New Acceptors Other Acceptors (Present Month) (End of Month) (Present Month)
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4) (Col. 5) (Col. 6) (Col. 7)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total
g.1 IUD-I- Total
• NHTS
• Non-NHTS
g.2 IUD-PP - Total
• NHTS
• Non-NHTS
h. NFP-LAM - Total
• NHTS
• Non-NHTS
i. NFP-BBT - Total
• NHTS
• Non-NHTS
j. NFP-CMM - Total
• NHTS
• Non-NHTS
k. NFP-STM - Total
• NHTS
• Non-NHTS
l. NFP-SDM - Total
• NHTS
• Non-NHTS
m. Total Current Users
• NHTS
• Non-NHTS
Section B. Maternal Care and Services
Indicators Age Total Remarks Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3) (Col. 4) (Col. 1) (Col. 2) (Col 3) (Col. 4)
10-14 15-19 20-49 10-14 15-19 20-49
B1. Prenatal Care
1. No. of pregnant women w/ b. No. of pregnant women seen in the first
at least 4 prenatal check- trimester who have low BMI - Total
ups - Total
• NHTS • NHTS
• Non-NHTS • Non-NHTS
2. No. of pregnant women c. No. of pregnant women seen in the first
assessed of their nutritional trimester who have high BMI - Total
status during the 1st tri. -Total
• NHTS • NHTS
a. Number of pregnant women 3. No. of pregnant women for the first time
seen in the first trimester who given 2 doses of Td vaccination - Total
have normal BMI - Total
• NHTS • NHTS
2
10-14 15-19 20-49 10-14 15-19 20-49
B1. Prenatal Care
4. No. of pregnant women for the 11. No. of pregnant women screened for
2nd or more times given at least Hepatitis B - Total
3 doses of Td vaccination (Td2
Plus)
• NHTS- Total • NHTS
5. No. of pregnant women who 12. No. of pregnant women tested positive for
completed the dose of iron with Hepatitis B - Total
folic acid supplementation -
Total
• NHTS • NHTS
6. No. of pregnant women who 13. No. of pregnant women screened for HIV
completed doses of calcium - Total
carbonate supplementation -
Total
• NHTS • NHTS
7. No. of pregnant women given 14. No. of pregnant women tested for CBC or
iodine capsules – Total Hgb&Hct count - Total
• NHTS • NHTS
8. No. of pregnant women given 15. No. of pregnant women tested for CBC or
one dose of deworming tablet - Hgb&Hct count diagnosed with anemia -
Total Total
• NHTS • NHTS
9. No. of pregnant women 16. No. of pregnant women screened for
screened for syphilis - Total gestational diabetes – Total
• NHTS • NHTS
10. No. of pregnant women tested 17. No. of pregnant women tested positive
positive or syphilis - Total for gestational diabetes – Total
• NHTS • NHTS
10-14 15-19 20-49 10-14 15-19 20-49
B2. Intrapartum Care and Delivery Outcome
18. No. of deliveries – Total 20a. No. of live births with normal birth weight
- Total
• NHTS • NHTS
19. No. of live births – Total 20b. No. of live births with low birth weight -
Total
• NHTS • NHTS
3
10-14 15-19 20-49 10-14 15-19 20-49
B2. Intrapartum Care and Delivery Outcome
20c. No. of live births with 24a. No. of deliveries in public health
unknown birth weight- Total facility - Total
• NHTS • NHTS
21. No. of deliveries attended by 24b. No. of deliveries in private health
skilled health professionals - Total facility - Total
• NHTS • NHTS
a. No. of deliveries attended 25. No. of non-facility-based deliveries -
by a doctor - Total Total
• NHTS • NHTS
b. No. of deliveries attended 26a. No. of vaginal deliveries – Total
by a nurse – Total
• NHTS • NHTS
c. No. of deliveries attended 26b. No. of deliveries by cesarean
by midwives - Total section – Total
• NHTS • NHTS
22. No. of deliveries attended 27a. No. of full-term births – Total
by non-skilled health
•professionals
NHTS - Total • NHTS
a. No. of deliveries attended 27b. No. of pre-term births – Total
by Hilot/TBA - Total
• NHTS • NHTS
b. No. of deliveries attended 27c. No. of fetal deaths - Total
by others - Total
• NHTS • NHTS
23. No. of health facility-based 27d. No. of abortion/miscarriage - Total
deliveries - Total
• NHTS • NHTS
4
10-14 15-19 20-49 10-14 15-19 20-49
B3. Postpartum and Newborn Care
28. No. of postpartum women 29. No. of postpartum women who completed
together with their newborn iron with folic acid supplementation - Total
who completed at least 2
postpartum check-ups - Total
• NHTS • NHTS
30. No. of postpartum women with
Vitamin A supplementation – Total
• NHTS
• Non-NHTS
Section C. Child Care and Services
Indicators Male Female Total Indicators Male Female Total Indicators Male Female Total
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3) (Col 4)
C1. Immunization Services
1. CPAB - Total 8. OPV 2 - Total 15. MCV 2 - Total
• NHTS • NHTS • NHTS
• Non-NHTS • Non-NHTS • Non-NHTS
2. BCG - Total 9. OPV 3 - Total 16. FIC - Total
3. HepB, within 24 hours. - Total 10. IPV - Total 17. CIC - Total
4. DPT-HiB-HepB 1 - Total 11. PCV 1 - Total 18. Td, Grade 1 (November) - Total
5. DPT-HiB-HepB 2 - Total 12. PCV 2 - Total 19. MR, Grade 1 (November) - Total
6. DPT-HiB-HepB 3 - Total 13. PCV 3 - Total 20. Td, Grade 7 (November) - Total
7. OPV 1 - Total 14. MCV 1 - Total 21. MR, Grade 7 (November) - Total
C2. Nutrition Services
22. Newborns initiated on breastfeeding
23. Preterm/LBW infants given iron
immediately after birth lasting to 90 mins - 24. Infants 6 mos. old seen - Total
supplementation - Total
Total
5
C2. Nutrition Services
25. Infants exclusively breastfed until 6th month - 31. Children 12-59 mos. old given 2
28. Infants 6-11 mos. old seen - Total
Total doses of Vitamin A 200,000 I.U. - Total
26. Infants 6 mos. old initiated to complementary 29. Infants 6-11 mos. given 1 dose of 32. Infant 6-11 months old who completed
feeding with continued breastfeeding - Total Vitamin A 100,000 I.U. - Total MNP supplementation - Total
27. Infants 6 mos. old initiated to complementary
feeding but no longer or never been breastfed 30. Children 12-59 mos seen - Total 33. Children 12-23 mos. seen - Total
- Total
C3. Deworming Services
34. Children 12-23 mos. who completed 38. Adolescents, 10-19 y/o dewormed
36. PSAC, 1-4 y/o dewormed (2 doses) -Total
MNP supplementation - Total (2 doses) - Total
35. 1-19 y/o given 2 doses of deworming 37. SAC, 5-9 y/o dewormed (2 doses) -
drug - Total Total
• NHTS • NHTS
C4. Management of Sick Infants and Children
39. Sick Infants 6-11 mos. old seen - Total 42. Sick Children 12-59 mos. old 45. Diarrhea cases 0-59 mos. received
received Vitamin A - Total ORS w/ zinc - Total
40. Sick Infants 6-11 mos. old received 43. Diarrhea cases 0-59 months old seen 46. Pneumonia cases 0-59 mos. old
Vitamin A - Total - Total seen - Total
44. Diarrhea cases 0-59 months old 47. Pneumonia cases 0-59 mos. old
41. Sick Children 12-59 mos. old seen - Total
received ORS - Total completed treatment - Total
Section D. Oral Care and Services
To be submitted Quarterly
1. Orally fit children 12-59 months old upon oral 2. Clients 5 years old and above with new 3. Infants 0-11 months old who received
exam plus orally fit after rehab - Total cases of DMFT - Total BOHC - Total
6
4. Children 1-4 years old who received 6. Adolescents 10-19 years old who 8. Senior citizens 60 years old and above
BOHC - Total received BOHC - Total who received BOHC - Total
Indicators 20-49 20-49 20-49 Total
5. Children 5-9 years old who received 7. Adults 20-59 years old who received
9. Pregnant women who received BOHC
BOHC - Total BOHC - Total
- Total
Section E. Infectious Disease Prevention and Control Services
E1. Filariasis Prevention and Control (to be reported annually)
E2. Schistosomiasis Prevention and Control
7. No. of confirmed cases (acute and
1. No. of patients seen - Total 4. No. of confirmed acute cases - Total
chronic) - Total
5. No. of chronic clinically diagnosed
2. No. of suspected cases seen 8. No. of cases treated - Total
cases - Total
9. No. of confirmed chronic cases
3. No. acute clinically diagnosed cases - Total 6. No. confirmed chronic cases - Total
referred to a hospital facility - Total
E3. Soil Transmitted Helminthiasis Prevention and Control (reflected under Child Care, Family Planning and Maternal Care)
E4. HIV-AIDS/STI Prevention and Control (reflected under Maternal Care)
E5. Tuberculosis Prevention and Control
1. Number of notified TB cases, all forms - Total 3. Number of TB, all forms that are cured 4. No. of registered bacteriology confirmed
and completely treated - Total drug resistant TB Cases (RR/MDR-TB)
2. No. of registered bacteriologically confirmed cured & completed treatment - Total
drug resistant TB (RR/MDR-TB Cases)-Total
E6. Malaria Prevention and Control
1. No. of patients with probable/clinically 2. No. of lab-confirmed Malaria deaths -
diagnosed malaria and confirmed case-Total Total
• < 5 y/o - Total • < 5 y/o - Total
• ≥ 5 y/o - Total • ≥ 5 y/o - Total
E7. Leprosy Prevention and Control E8. Rabies Prevention and Control
1. No. of Leprosy Cases on treatment during 2. No. of newly detected cases during 1. No. of deaths due to rabies - Total
reporting period - Total reporting period - Total
Section F. Non-Communicable Disease Prevention and Control Services
3. Alcohol binge drinker - Total 5. No. of adult women screened for
1. No. of adults risk-assessed using PhilPEN - Cervical Cancer using VIA/Pap Smear
Total - Total
2. Current smoker - Total 4. Overweight/Obese - Total 6. No. of adult women found positive /
suspect for Cervical Cancer using VIA
or Pap Smear - Total
7
7. No. of adult women screened for breast mass 10. No. of newly-identified adults with Type 13. No. of senior citizens who received
- Total 2 DM-Total one (1) dose of PPV - Total
14. No. of senior citizens who received
8. No. of adult women with suspicious breast 11. No. of senior citizens screened for one (1) dose of influenza vaccine -
mass - Total visual acuity - Total Total
9. No. of newly-identified hypertensive adults 12. No. of senior citizens diagnosed with
- Total eye disease/s - Total
• NHTS • NHTS
Section G. Environmental Health and Sanitation Services
Indicators Total Indicators Total
(Col. 1) (Col. 2) (Col. 1) (Col. 2)
1. No. of HHs with access to basic safe water supply - Total 3.1 No. of HH with pour/flush toilet connected to septic tank - Total
• NHTS • NHTS
1.1 No. of HHs with Level I - Total 3.2 No. of HHs with pour/flush toilet connected to community sewer/
• NHTS sewerage system or any other approved treatment system - Total
• Non-NHTS • NHTS
1.2 No. of HHs with Level II - Total • Non-NHTS
• NHTS 3.3 No. of HHs with ventilated improved pit latrine (VIP) - Total
• Non-NHTS • NHTS
1.3 No. of HHs with Level III - Total • Non-NHTS
• NHTS 4. No. of industrial establishments issued with sanitary permit - Total
• Non-NHTS
3. No of HHs with basic sanitation facility - Total
• NHTS
• Non-NHTS
Section H. _____________________________________

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FHSIS REPORT for the MONTH: __ YEAR: _

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