M1

FHSIS REPORT for the: MONTH: YEAR:

Name of Barangay:
Name of BHS:
Name of Municipality/City:
Name of Province:

BRGY
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 Total
(Col. 1) (Col. 2) (Col. 3) (Col. 1) (Col. 3)
15-19 20-49
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
Current User Acceptors Dropout Current User New Acceptors
A2. Use of FP Method (Beginning Month) New Acceptors Other Acceptors (Present Month) (End of Month) (Present Month)
(Previous Month) (Present Month)
(Col. 2) (Col. 3) (Col. 4) (Col. 5) (Col. 6) (Col. 7)
(Col. 1)
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

b. Male Sterilization / NSV - Total

c. Condom - Total

d. Pills - Total

d.1 Pills-POP - Total

d.2 Pills-COC - Total

e. Injectables (DMPA/POI) - Total

f. Implant - Total

g. IUD (IUD-I and IUD-PP) - Total

g.1 IUD-I - Total

g.2 IUD-PP - Total

h. NFP-LAM - Total

i. NFP-BBT - Total

j. NFP-CMM - Total

k. NFP-STM - Total

l. NFP-SDM - Total

FHSIS ver. 2018 M1-HPA | Page 1 of 24

m. Total Current Users

FHSIS ver. 2018 M1-HPA | Page 2 of 24

 FHSIS report for the: MONTH: YEAR: Barangay: City/Municipality: Province:
Section B. Maternal Care and Services
Indicators Age Indicators Age
Total Remarks Total Remarks
(Col. 1) (Col. 2) (Col. 1) (Col. 2)
(Col 3)  (Col. 4) (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/ at least 4 11. No. of pregnant women screened

prenatal check-ups - Total for Hepatitis B - Total

2. No. of pregnant women

12. No. of pregnant women
assessed of their nutritional
tested positive for Hepatitis B - Total
status during the 1st trimester - Total
a. No. of pregnant women seen in the
13. No. of pregnant women
first trimester who have normal
screened for HIV - Total
BMI - Total
b. No. of pregnant women seen in the
14. No. of pregnant women tested for
first trimester who have low BMI
CBC or Hgb&Hct count - Total
- Total
c. No. of pregnant women seen in the 15. No. of pregnant women tested for
first trimester who have high BMI CBC or Hgb&Hct count diagnosed
- Total with anemia - Total
3. No. of pregnant women for
16. No. of pregnant women screened for
the first time given 2 doses
gestational diabetes – Total
of Td vaccination - Total
4. No. of pregnant women for the 2nd or 17.   No. of pregnant women tested
more times given at least 3 doses of positive for gestational diabetes
Td vaccination (Td2 Plus) - Total – Total
5. No. of pregnant women who B2. Intrapartum Care and Delivery Outcome
completed the dose of iron
with folic acid supplementation - Total 18. No. of deliveries – Total

6. No. of pregnant women who

completed doses of calcium 19. No. of live births – Total
carbonate supplementation - Total

7. No. of pregnant women given iodine 20a. No. of live births with normal birth
capsules - Total weight - Total

8. No. of pregnant women given one 20b. No. of live births with low birth
dose of deworming tablet - Total weight - Total

9. No. of pregnant women screened for 20c. No. of live births with unknown
syphilis - Total birth weight - Total

FHSIS ver. 2018 M1-HPA | Page 3 of 24

10. No. of pregnant women tested 21. No. of deliveries attended by
positive for syphilis - Total skilled health professionals - Total

FHSIS ver. 2018 M1-HPA | Page 4 of 24

 FHSIS report for the: MONTH: YEAR: Barangay: City/Municipality: Province:
Section B. Maternal Care and Services
Indicators Age Indicators Age
Total Remarks Total Remarks
(Col. 1) (Col. 2) (Col. 1) (Col. 2)
(Col 3)  (Col. 4) (Col 3)  (Col. 4)
 10-14  15-19 20-49  10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome

a. No. of deliveries attended

26a. No. of vaginal deliveries – Total
by a doctor - Total

b. No. of deliveries attended 26b. No. of deliveries by cesarean

by a nurse – Total section – Total

c. No. of deliveries attended

27a. No. of full-term births – Total
by midwives - Total
22. No. of deliveries attended by
non-skilled health professionals 27b. No. of pre-term births – Total
- Total
a. No. of deliveries attended
27c. No. of fetal deaths - Total
by Hilot/TBA - Total

b. No. of deliveries attended 27d. No. of abortion/

by others - Total miscarriage - Total
B3. Postpartum and Newborn Care
23. No. of health facility-based 28. No. of postpartum women together with
deliveries - Total their newborn who completed at least 2
postpartum check-ups - Total
29. No. of postpartum women who
24a. No. of deliveries in public health
completed iron with folic acid
facility - Total
supplementation - Total
24b. No. of deliveries in private health 30. No. of postpartum women with
facility - Total Vitamin A supplementation – Total

25. No. of non-facility-based deliveries -

Total
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 16. FIC - Total
2. BCG - Total 9. OPV 3 - Total 17. CIC - Total
3. HepB, within 24 hours. - Total 10. IPV - Total 18. Td, Grade 1 (November) - Total
4. DPT-HiB-HepB 1 - Total 11. PCV 1 - Total 19. MR, Grade 1 (November) - Total
5. DPT-HiB-HepB 2 - Total 12. PCV 2 - Total 20. Td, Grade 7 (November) - Total
6. DPT-HiB-HepB 3 - Total 14. MCV 1 - Total 21. MR, Grade 7 (November) - Total

FHSIS ver. 2018 M1-HPA | Page 5 of 24

7. OPV 1 - Total 15. MCV 2 - Total

FHSIS ver. 2018 M1-HPA | Page 6 of 24

 FHSIS report for the: MONTH: YEAR: Barangay: City/Municipality: Province:
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)
C2. Nutrition Services
22. Newborns initiated on breastfeeding 27. Infants 6 mos. old initiated to 32. Infant 6-11 months old who
immediately after birth lasting to 90 mins - Total complementary feeding but no completed MNP supplementation
longer or never been breastfed - Total
- Total

23. Preterm/LBW infants given iron 28. Infants 6-11 mos. old seen - Total 33. Children 12-23 mos. seen - Total
supplementation - Total
24. Infants 6 mos. old seen - Total 29. Infants 6-11 mos. given 1 dose of 34. Children 12-23 mos. who completed
Vitamin A 100,000 I.U. - Total MNP supplementation - Total
25. Infants exclusively breastfed until 30. Children 12-59 mos seen - Total
6th month - Total
26. Infants 6 mos. old initiated to 31. Children 12-59 mos. old given 2
complementary feeding with doses of Vitamin A 200,000 I.U. -
continued breastfeeding - Total Total
C3. Deworming Services
37. SAC, 5-9 y/o dewormed (2 doses)
35. 1-19 y/o given 2 doses of deworming drug - Total
- Total
38. Adolescents, 10-19 y/o dewormed
36. PSAC, 1-4 y/o dewormed (2 doses) - Total
(2 doses) - Total
C4. Management of Sick Infants and Children
42. Sick Children 12-59 mos. old 45. Diarrhea cases 0-59 mos. received
39. Sick Infants 6-11 mos. old seen - Total
received Vitamin A - Total ORS w/ zinc - Total
40. Sick Infants 6-11 mos. old received 43. Diarrhea cases 0-59 months old 46. Pneumonia cases 0-59 mos. old
Vitamin A - Total seen - 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
Section E. Infectious Disease Prevention and Control 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)
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)
FHSIS ver. 2018 M1-HPA | Page 7 of 24
E4. HIV-AIDS/STI Prevention and Control (reflected under Maternal Care)

FHSIS ver. 2018 M1-HPA | Page 8 of 24

 FHSIS report for the: MONTH: YEAR: Barangay: City/Municipality: Province:
Section E. Infectious Disease Prevention and Control 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)
E5. Tuberculosis Prevention and Control
3. Number of TB, all forms that are cured 4. No. of registered bacteriology
1. Number of notified TB cases, all forms - Total and completely treated - Total confirmed drug resistant TB Cases
(RR/MDR-TB) cured & completed
2. No. of registered bacteriologically confirmed
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 reporting period - 2. No. of newly detected cases during 1. No. of deaths due to rabies - Total
Total reporting period - Total
Section F. Non-Communicable Disease Prevention and Control 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)
1. No. of adults risk-assessed using PhilPEN - 5. No. of adult women screened for 10. No. of newly-identified adults with
Total Cervical Cancer using VIA/Pap Type 2 DM - Total
Smear - Total
2. Current smoker - Total 6. No. of adult women found positive / 11. No. of senior citizens screened for
suspect for Cervical Cancer using visual acuity - Total
VIA or Pap Smear - Total
3. Alcohol binge drinker - Total 7. No. of adult women screened for 12. No. of senior citizens diagnosed
breast mass - Total with eye disease/s - Total

4. Overweight/Obese - Total 8. No. of adult women with suspicious 13. No. of senior citizens who received
breast mass - Total one (1) dose of PPV - Total

9. No. of newly-identified hypertensive 14. No. of senior citizens who received

adults - Total one (1) dose of influenza vaccine -
Total
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. No of HHs with basic sanitation facility - Total
1.1 No. of HHs with Level I - Total 3.1 No. of HH with pour/flush toilet connected to septic tank - Total
1.2 No. of HHs with Level II - Total 3.2 No. of HHs with pour/flush toilet connected to community sewer/
1.3 No. of HHs with Level III - Total sewerage system or any other approved treatment system - Total

FHSIS ver. 2018 M1-HPA | Page 9 of 24

5. No. of industrial establishments issued with sanitary permit - Total 3.3 No. of HHs with ventilated improved pit latrine (VIP) - Total

FHSIS ver. 2018 M1-HPA | Page 10 of 24

 M1
FHSIS Monthly Report for: MONTH: YEAR:
Name of Health Facility:
Name of Barangay:
Name of Municipality/City:
Name of Province:
Projected Population of the Year:

For submission to the RHU/MHC

BRGY
Section H.1 Mortality
Indicators Male Female Total Rate
No.
(Col. 1) (Col. 2) (Col. 3) (Col. 4) (Col. 5)
1. Total Deaths

2. Maternal Deaths - Total

3. Under-five Deaths - Total

4. Infant Deaths - Total

5. Neonatal Deaths - Total

6. Fetal Deaths - Total

7. Early Neonatal Deaths - Total

8. Perinatal Deaths - Total

Section H.2 Natality

Age group of Mother
Indicators Total Rate
No. 10-14 y/o 15-19 y/o 20-49 y/o

(Col. 1) (Col. 2) (Col. 3) (Col. 4) (Col. 6) (Col. 7)

CBR:
1. Live births 10-14 y/o:
15-19 y/o:

FHSIS ver. 2018 M1-Mortality and Natality

 M1
FHSIS Quarterly Report for: QUARTER: YEAR: Prepared by:
Name of Health Facility: Name and Designation
Name of Barangay:
Name of Municipality/City:
Name of Province: Noted by:
Projected Population of the Year: Municipal/City Health Officer

Section H.3 MORTALITY REPORT

For submission to the PHO
M/CHO
DISEASE 29 days-11
0-6 days 7-28 days 1-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 ≥ 70 TOTAL
ICD 10 Code mos
(Underlying Cause) M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F Both
Total, all causes A00-Y99

FHSIS ver. 2018 M1-Mortality

 M1
FHSIS Quarterly Report for: QUARTER: YEAR: Prepared by:
Name of Health Facility: Name and Designation
Name of Barangay:
Name of Municipality/City:
Name of Province: Noted by:
Projected Population of the Year: Municipal/City Health Officer

Section H.3 MORTALITY REPORT

For submission to the PHO
M/CHO
DISEASE 29 days-11
0-6 days 7-28 days 1-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 ≥ 70 TOTAL
ICD 10 Code mos
(Underlying Cause) M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F Both

FHSIS ver. 2018 M1-Mortality

 M2
FHSIS Quarterly Report for: MONTH: YEAR: Prepared by:
Name of Health Facility: Name and Designation
Name of Barangay:
Name of Municipality/City:
Name of Province: Noted by:
Projected Population of the Year: Name and Designation

Section A.1 MORBIDITY REPORT

For submission to the next administrative level
DISEASE 29 days-11
0-6 days 7-28 days 1-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 ≥ 70 TOTAL
ICD 10 Code mos
(Underlying Cause) M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F Both
Total, all causes A00-Y99

Cholera A00.0-A00.9
A09.0
Acute Watery Diarrhea
(watery)
A09.0
Acute Bloody Diarrhea
(bloody)
Typhoid and Paratyphoid Fever A01.1-A01.4

Leptospirosis A27.0-A27.9

Leprosy A30.0-A30.9

Neonatal Tetanus A33

Non-neonatal Tetanus A35

Diphtheria A36.0-A36.9

Meningococcemia A39.2-A39.4

Syphilis A50-A53

Gonorrhea A54.0-A54.9

Viral Encephalitis A83-A86

Viral Meningitis A87.0-A87.9

Acute Hemorrhagic Fever Syndrome
A97.0-A97.2
(Dengue)
Measles B05.0-B05.9

Acute Viral Hepatitis B15-B17

Malaria B50-B54

Schistosomiasis B65.0-B65.9

Filariasis B74.0-B74.9

Acute Flaccid Paralysis G83.9

Influenza-like Illness J11.1

FHSIS ver. 2018 Q1-Mortality

 M2
FHSIS Quarterly Report for: MONTH: YEAR: Prepared by:
Name of Health Facility: Name and Designation
Name of Barangay:
Name of Municipality/City:
Name of Province: Noted by:
Projected Population of the Year: Name and Designation

Section A.1 MORBIDITY REPORT

For submission to the next administrative level
DISEASE 29 days-11
0-6 days 7-28 days 1-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 ≥ 70 TOTAL
ICD 10 Code mos
(Underlying Cause) M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F Both
Influenza J11.1

Pneumonia J18.90-J18.99

FHSIS ver. 2018 Q1-Mortality

 M2
FHSIS Quarterly Report for: MONTH: YEAR: Prepared by:
Name of Health Facility: Name and Designation
Name of Barangay:
Name of Municipality/City:
Name of Province: Noted by:
Projected Population of the Year: Name and Designation

Section A.1 MORBIDITY REPORT

For submission to the next administrative level
DISEASE 29 days-11
0-6 days 7-28 days 1-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 ≥ 70 TOTAL
ICD 10 Code mos
(Underlying Cause) M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F Both
Acute Lower Respiratory Tract
J22
Infection
N48.5, N50.8,
Genital ulcer N76.5, N76.6,
N89.8
Urethral Discharge R36

Animal Bites T14.1

Paralytic Shellfish Poisoning T61.2

Other Diseases

ARI in below 5 J22

ARI for 5 and above J22

Fever of Unknown Origin R50.9

Acute Febrile Illness R50.9

Bronchitis, Chronic J40

Bronchitis, Acute J20.9

Chickenpox B01.89
Chronic Obstructive Pulmonary
J44.0-J44.9
Disease (COPD)
Hypertension I10.0-I10.9

Skin Diseases

Tuberculosis, Other Forms

Tuberculosis, Respiratory

Urinary Tract Infection

Whooping Cough
I00-I09, I11,
Diseases of the Heart
I13, I20-I51

FHSIS ver. 2018 Q1-Mortality

 M2
FHSIS Quarterly Report for: MONTH: YEAR: Prepared by:
Name of Health Facility: Name and Designation
Name of Barangay:
Name of Municipality/City:
Name of Province: Noted by:
Projected Population of the Year: Name and Designation

Section A.1 MORBIDITY REPORT

For submission to the next administrative level
DISEASE 29 days-11
0-6 days 7-28 days 1-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 ≥ 70 TOTAL
ICD 10 Code mos
(Underlying Cause) M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F Both

FHSIS ver. 2018 Q1-Mortality

 M2
FHSIS Quarterly Report for: MONTH: YEAR: Prepared by:
Name of Health Facility: Name and Designation
Name of Barangay:
Name of Municipality/City:
Name of Province: Noted by:
Projected Population of the Year: Name and Designation

Section A.1 MORBIDITY REPORT

For submission to the next administrative level
DISEASE 29 days-11
0-6 days 7-28 days 1-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 ≥ 70 TOTAL
ICD 10 Code mos
(Underlying Cause) M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F Both

FHSIS ver. 2018 Q1-Mortality

 M2
FHSIS Quarterly Report for: MONTH: YEAR: Prepared by:
Name of Health Facility: Name and Designation
Name of Barangay:
Name of Municipality/City:
Name of Province: Noted by:
Projected Population of the Year: Name and Designation

Section A.1 MORBIDITY REPORT

For submission to the next administrative level
DISEASE 29 days-11
0-6 days 7-28 days 1-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 ≥ 70 TOTAL
ICD 10 Code mos
(Underlying Cause) M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F Both

FHSIS ver. 2018 Q1-Mortality

 FHSIS REPORT for the MONTH: YEAR:

M2
Name of Health Facility:
Name of Barangay:
Name of Municipality/City:
Name of Province:
Projected Population of the Year:

For submission to the next administrative level

Section A.2.a Ten Leading Causes of Morbidity in all Age Groups

Name of Disease Number of Cases Rate per 100,000 population
No.
(Col. 1.) (Col. 3) (Col. 4)
1.

2.

3.

4.

5.

6.

7.

8.

9.

10.
Section A.2.b Ten Leading Causes of Morbidity in Males
Name of Disease Number of Cases Rate per 100,000 population
No.
(Col. 1.) (Col. 3) (Col. 4)
1.

2.

3.

4.

5.

6.

7.

8.

9.

10.
Section A.2.c Ten Leading Causes of Morbidity in Females
Name of Disease Number of Cases Rate per 100,000 population
No.
(Col. 1.) (Col. 3) (Col. 4)
1.

2.

3.

4.

5.

6.

7.

8.

9.

10.
Section A.2.d Ten Leading Causes of Morbidity in Under-Five Children
Name of Disease Number of Cases Rate per 100,000 population
No.
(Col. 1.) (Col. 3) (Col. 4)
1.

2.

3.

4.

5.

6.

7.

8.

FHSIS ver. 2018 M2-Morbidity | Page 1 of 24

 FHSIS REPORT for the MONTH: YEAR:

M2
Name of Health Facility:
Name of Barangay:
Name of Municipality/City:
Name of Province:
Projected Population of the Year:

For submission to the next administrative level

9.

10.

FHSIS ver. 2018 M2-Morbidity | Page 2 of 24

 FHSIS REPORT for the MONTH: YEAR:

M2
Name of Health Facility:
Name of Barangay:
Name of Municipality/City:
Name of Province:
Projected Population of the Year:

For submission to the next administrative level

Section A.2.e Ten Leading Causes of Morbidity in Adolescents 10-19 Years Old
Name of Disease Number of Cases Rate per 100,000 population
No.
(Col. 1.) (Col. 3) (Col. 4)
1.

2.

3.

4.

5.

6.

7.

8.

9.

10.
Section A.2.f Ten Leading Causes of Morbidity in Senior Citizens ≥ 60 years old
Name of Disease Number of Cases Rate per 100,000 population
No.
(Col. 1.) (Col. 3) (Col. 4)
1.

2.

3.

4.

5.

6.

7.

8.

9.

10.
Section A.2.g Ten Leading Causes of Morbidity in Pregnant Women
Name of Disease Number of Cases Rate per 100,000 population
No.
(Col. 1.) (Col. 3) (Col. 4)
1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

Prepared by: Noted by:

Name and Designation Name and Designation

FHSIS ver. 2018 M2-Morbidity | Page 3 of 24

 FHSIS REPORT for the MONTH: YEAR:

M2
Name of Health Facility:
Name of Barangay:
Name of Municipality/City:
Name of Province:
Projected Population of the Year:

For submission to the next administrative level

Section B. Program F1 PLUS Indicators

Indicators Male Female Total
No.
(Col. 1.) (Col. 2) (Col. 3) (Col. 4)
1. No. of WRA using modern FP methods - Total
No. of pregnant women w/ at least 4 prenatal check-ups -
2.
Total
3. No. of births delivered by adolescents (10-19 y/o) - Total
4. No. of live births with low birth weight - Total
No. of deliveries attended by skilled health professionals -
5.
Total
No. of postpartum women together with their newborn who
6.
completed at least 2 postpartum check-ups - Total
7. No. of health facility-based deliveries - Total
8. No. of fully immunized children - Total
Section C. Mortality F1 PLUS Indicators
Indicators Male Female Total
No.
(Col. 1.) (Col. 2) (Col. 3) (Col. 4)
1. Maternal Deaths - Total
2. Infant Deaths - Total

Prepared by: Noted by:

FHSIS ver. 2018 M2-F1 PLUS | Page 1 of 24

Signature Over Printed Name and Designation Signature Over Printed Name and Designation

FHSIS ver. 2018 M2-F1 PLUS | Page 2 of 24