FHSIS REPORT for the MONTH: ___JANUARY_____

Name of Barangay: _____TAGPAKO_________

Name of BHS: _______________________
Name of Municipality/City: _______________________
Name of Province: ________________________
Projected Population of the Year: _______________________
For submission to RHU/MHC

Section A. Family Planning Services and Dewor

A1. Modern FP Unmet Need Age Total

(Col. 1) (Col. 2) (Col. 3)

10-14 15-19 20-49
1. No. of WRA with unmet
need for modern FP - Total 5 5 5
15
• NHTS 5 5 5 15
• Non-NHTS 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
a. Female Sterilization/ BTL - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
b. Male Sterilization/ NSV-Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
c. Condom - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d. Pills - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
 d.1 Pills-POP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d.2 Pills-COC - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
e. Injectables (DMPA/ POI) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
f. Implant - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g. IUD (IUD-I and IUD-PP) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.1 IUD-I- Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.2 IUD-PP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
h. NFP-LAM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
i. NFP-BBT - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
j. NFP-CMM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
k. NFP-STM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
l. NFP-SDM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
m. Total Current Users 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
Section B. Maternal Care
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
1. No. of pregnant women w/
at least 4 prenatal check-
ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
2. No. of pregnant women
assessed of their nutritional
status during the 1st tri. -Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
c. No. of pregnant women
seen in the first trimester
who have high BMI - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
3. No. of pregnant women for
the first time given 2 doses of
Td vaccination - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
4. No. of pregnant women for
the 2nd or more times given
at least 3 doses of Td
vaccination (Td2 Plus) - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
5. No. of pregnant women who
completed the dose of iron
with folic acid
supplementation - Total 0 0 0 0
 • NHTS 0
• Non-NHTS 0
6. No. of pregnant women who
completed doses of calcium
carbonate supplementation -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
12. No. of pregnant women
tested positive for Hepatitis
B - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
13. No. of pregnant women
screened for HIV - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
14. No. of pregnant women
tested for CBC or Hgb&Hct
count - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
15. No. of pregnant women
tested for CBC or Hgb&Hct
count diagnosed with
anemia - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
16. No. of pregnant women
screened for gestational
diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
17.   No. of pregnant women
tested positive for
gestational diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col 3)  (Col. 4)
 Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
a. No. of deliveries attended
by a doctor - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by a nurse – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
c. No. of deliveries attended
by midwives - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
22. No. of deliveries attended by
non-skilled health
professionals - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
a. No. of deliveries attended
by Hilot/TBA - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by others - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
23. No. of health facility-based
deliveries - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
27c. No. of fetal deaths - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
27d. No. of abortion/
miscarriage - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0

Section C. Child Care a

Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
C1. Immunization Services
1. CPAB - Total 0 0 0 6. DPT-HiB-HepB 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
2. BCG - Total 0 0 0 7. OPV 1 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
3. HepB, within 24 hours. - Total 0 0 0 8. OPV 2 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
4. DPT-HiB-HepB 1 - Total 0 0 0 9. OPV 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
5. DPT-HiB-HepB 2 - Total 0 0 0 10. IPV - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
16. FIC - Total 0 0 0 18. Td, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
17. CIC - Total 0 0 0 19. MR, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
C2. Nutrition Services
22. Newborns initiated on breastfeeding
immediately after birth lasting to 90 mins - 28. Infants 6-11 mos. old seen - Total
Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
23. Preterm/LBW infants given iron 29. Infants 6-11 mos. given 1 dose of
supplementation - Total 0 0 0 Vitamin A 100,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
24. Infants 6 mos. old seen - Total 0 0 0 30. Children 12-59 mos seen - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
25. Infants exclusively breastfed until 6th month - 31. Children 12-59 mos. old given 2
Total 0 0 0 doses of Vitamin A 200,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
26. Infants 6 mos. old initiated to complementary 32. Infant 6-11 months old who completed
feeding with continued breastfeeding - Total 0 0 0 MNP supplementation - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
27. Infants 6 mos. old initiated to complementary
feeding but no longer or never been breastfed 33. Children 12-23 mos. seen - Total
- Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
0
40. 1-19 y/o given 2 doses of deworming drug - 42. SAC, 5-9 y/o dewormed (2 doses) -
Total 0 0 0 Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
41. PSAC, 1-4 y/o dewormed (2 doses) - Total 0 0 0
• NHTS 0
• Non-NHTS 0
0
44. Sick Infants 6-11 mos. old seen - Total 47. Sick Children 12-59 mos. old
0 0 0 received Vitamin A - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
45. Sick Infants 6-11 mos. old received 48. Diarrhea cases 0-59 months old seen
Vitamin A - Total 0 0 0 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
49. Diarrhea cases 0-59 months old
46. Sick Children 12-59 mos. old seen - Total
0 0 0 received ORS - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
 To be submitted Qua
Section E. Infectious Disease Preven
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
E1. Filariasis Prevention and Control E2. Schistosomiasis Prevention and Contro
1. No. of individual examined for lymphatic 1. No. of people 5-65 y/o who ingested
filariasis - Total 0 MDA drugs - Total
2. No. of individual examined found positive for 2. No. of patients seen - Total
lymphatic filariasis - Total 0 3. No. of suspected cases seen
3. No. of lymphatic filariasis cases examined with 4. No. acute clinically diagnosed cases -
manifestation of either lymphedema,hydrocele, Total
elephantiasis - Total
0 5. No. of confirmed acute cases - Total
6. No. of chronic clinically diagnosed
cases - Total
Section F. _________________________
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
 ___JANUARY_____ YEAR: ____2020___

M1
AGPAKO__________________________
_________________________
_________________________

BRGY
________________________
________________________
r submission to RHU/MHC

Services and Deworming for Women of Reproductive Age

Total A3. Deworming Services SES Total

Col. 3) (Col. 1) (Col. 2) (Col. 3)

NHTS Non-NHTS
1. No. of women 20-49 years old given 2 doses of
15 deworming drugs - Total
0 0 0
15
0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
on B. Maternal Care and Services
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

a. Number of pregnant women seen in the

first trimester who have normal BMI -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of pregnant women seen in the first
trimester who have low BMI - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

7. No. of pregnant women given iodine

capsules – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
8. No. of pregnant women given one dose
of deworming tablet - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
9. No. of pregnant women screened for
syphilis - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
10. No. of pregnant women tested positive
for syphilis - Total

0 0 0 0
 • NHTS 0
• Non-NHTS 0
11. No. of pregnant women screened for
Hepatitis B - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
18. No. of deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
19. No. of live births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20a. No. of live births with normal birth
weight - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20b. No. of live births with low birth weight
- Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
20c. No. of live births with unknown birth
weight- Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
21. No. of deliveries attended by skilled
health professionals - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col 3)  (Col. 4)
rks Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

24a. No. of deliveries in public health

facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
24b. No. of deliveries in private health
facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
25. No. of non-facility-based deliveries -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
26a. No. of vaginal deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
26b. No. of deliveries by cesarean
section – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
27a. No. of full-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
27b. No. of pre-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B3. Postpartum and Newborn Care
28. No. of postpartum women together
with their newborn who completed at
least 2 postpartum check-ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
 29. No. of postpartum women who
completed iron with folic acid
supplementation - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
30. No. of postpartum women with
Vitamin A supplementation – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
ction C. Child Care and Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)

epB 3 - Total 0 0 0 11. PCV 1 - Total 0 0

0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 12. PCV 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 13. PCV 3 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 14. MMR 1 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
0 0 0 15. MMR 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
1 (November) - Total 0 0 0 20. Td, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
e 1 (November) - Total 0 0 0 21. MR, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

34. Children 12-23 mos. who completed

1 mos. old seen - Total
MNP supplementation - Total
0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
 1 mos. given 1 dose of
35. Children 0-59 mos. seen - Total
100,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos seen - Total 0 0 0 36. Stunted - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos. old given 2
37. Wasted - Total
tamin A 200,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
1 months old who completed
38. Overweight/Obese - Total
lementation - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS

2-23 mos. seen - Total 39. Normal - Total

0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col. 1) (Col 2) (Col 3)

y/o dewormed (2 doses) - 43. Adolescents, 10-19 y/o dewormed

0 0 0 (2 doses) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

ren 12-59 mos. old 50. Diarrhea cases 0-59 mos. received
itamin A - Total 0 0 0 ORS w/ zinc - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old seen 51. Pneumonia cases 0-59 mos. old
0 0 0 seen - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old 52. Pneumonia cases 0-59 mos. old
ORS - Total 0 0 0 completed treatment - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
 To be submitted Quarterly
ous Disease Prevention and Control Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
miasis Prevention and Control E2. Schistosomiasis Prevention and Control (Con't.)
le 5-65 y/o who ingested 7. No. confirmed chronic cases - Total
- Total 0
nts seen - Total 0 8. No. of confirmed cases (acute and
ected cases seen 0 chronic) - Total
clinically diagnosed cases - 9. No. of cases treated - Total
0
rmed acute cases - Total 0 10. No. of confirmed chronic cases
nic clinically diagnosed referred to a hospital facility - Total
al 0
_________________________________________
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
M1
RGY
Total

(Col. 3)

New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
 0 0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0 0
0
0
0 0
0
0
0 0
0
0
 0 0
0
0

Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
 Total
(Col 4)

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Total
(Col 4)
0
0
0
0
0
0

0
0
0
 0
0
0
0
0
0

0
0
0

0
0
0

0
0
0
Total
(Col 4)

0
0
0

0
0
0

0
0
0

0
0
0
 Total
(Col 4)
't.)

Total
(Col 4)
 FHSIS REPORT for the MONTH: ___JANUARY_____
Name of Barangay: _____TAGPAKO_________
Name of BHS: _______________________
Name of Municipality/City: _______________________
Name of Province: ________________________
Projected Population of the Year: _______________________
For submission to RHU/MHC

Section A. Family Planning Services and Dewor

A1. Modern FP Unmet Need Age Total

(Col. 1) (Col. 2) (Col. 3)

10-14 15-19 20-49
1. No. of WRA with unmet
need for modern FP - Total 5 5 5
15
• NHTS 5 5 5 15
• Non-NHTS 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
a. Female Sterilization/ BTL - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
b. Male Sterilization/ NSV-Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
c. Condom - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d. Pills - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
 d.1 Pills-POP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d.2 Pills-COC - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
e. Injectables (DMPA/ POI) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
f. Implant - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g. IUD (IUD-I and IUD-PP) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.1 IUD-I- Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.2 IUD-PP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
h. NFP-LAM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
i. NFP-BBT - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
j. NFP-CMM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
k. NFP-STM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
l. NFP-SDM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
m. Total Current Users 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
Section B. Maternal Care
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
1. No. of pregnant women w/
at least 4 prenatal check-
ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
2. No. of pregnant women
assessed of their nutritional
status during the 1st tri. -Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
c. No. of pregnant women
seen in the first trimester
who have high BMI - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
3. No. of pregnant women for
the first time given 2 doses of
Td vaccination - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
4. No. of pregnant women for
the 2nd or more times given
at least 3 doses of Td
vaccination (Td2 Plus) - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
5. No. of pregnant women who
completed the dose of iron
with folic acid
supplementation - Total 0 0 0 0
 • NHTS 0
• Non-NHTS 0
6. No. of pregnant women who
completed doses of calcium
carbonate supplementation -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
12. No. of pregnant women
tested positive for Hepatitis
B - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
13. No. of pregnant women
screened for HIV - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
14. No. of pregnant women
tested for CBC or Hgb&Hct
count - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
15. No. of pregnant women
tested for CBC or Hgb&Hct
count diagnosed with
anemia - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
16. No. of pregnant women
screened for gestational
diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
17.   No. of pregnant women
tested positive for
gestational diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col 3)  (Col. 4)
 Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
a. No. of deliveries attended
by a doctor - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by a nurse – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
c. No. of deliveries attended
by midwives - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
22. No. of deliveries attended by
non-skilled health
professionals - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
a. No. of deliveries attended
by Hilot/TBA - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by others - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
23. No. of health facility-based
deliveries - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
27c. No. of fetal deaths - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
27d. No. of abortion/
miscarriage - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0

Section C. Child Care a

Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
C1. Immunization Services
1. CPAB - Total 0 0 0 6. DPT-HiB-HepB 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
2. BCG - Total 0 0 0 7. OPV 1 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
3. HepB, within 24 hours. - Total 0 0 0 8. OPV 2 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
4. DPT-HiB-HepB 1 - Total 0 0 0 9. OPV 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
5. DPT-HiB-HepB 2 - Total 0 0 0 10. IPV - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
16. FIC - Total 0 0 0 18. Td, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
17. CIC - Total 0 0 0 19. MR, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
C2. Nutrition Services
22. Newborns initiated on breastfeeding
immediately after birth lasting to 90 mins - 28. Infants 6-11 mos. old seen - Total
Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
23. Preterm/LBW infants given iron 29. Infants 6-11 mos. given 1 dose of
supplementation - Total 0 0 0 Vitamin A 100,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
24. Infants 6 mos. old seen - Total 0 0 0 30. Children 12-59 mos seen - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
25. Infants exclusively breastfed until 6th month - 31. Children 12-59 mos. old given 2
Total 0 0 0 doses of Vitamin A 200,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
26. Infants 6 mos. old initiated to complementary 32. Infant 6-11 months old who completed
feeding with continued breastfeeding - Total 0 0 0 MNP supplementation - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
27. Infants 6 mos. old initiated to complementary
feeding but no longer or never been breastfed 33. Children 12-23 mos. seen - Total
- Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
0
40. 1-19 y/o given 2 doses of deworming drug - 42. SAC, 5-9 y/o dewormed (2 doses) -
Total 0 0 0 Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
41. PSAC, 1-4 y/o dewormed (2 doses) - Total 0 0 0
• NHTS 0
• Non-NHTS 0
0
44. Sick Infants 6-11 mos. old seen - Total 47. Sick Children 12-59 mos. old
0 0 0 received Vitamin A - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
45. Sick Infants 6-11 mos. old received 48. Diarrhea cases 0-59 months old seen
Vitamin A - Total 0 0 0 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
49. Diarrhea cases 0-59 months old
46. Sick Children 12-59 mos. old seen - Total
0 0 0 received ORS - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
 To be submitted Qua
Section E. Infectious Disease Preven
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
E1. Filariasis Prevention and Control E2. Schistosomiasis Prevention and Contro
1. No. of individual examined for lymphatic 1. No. of people 5-65 y/o who ingested
filariasis - Total 0 MDA drugs - Total
2. No. of individual examined found positive for 2. No. of patients seen - Total
lymphatic filariasis - Total 0 3. No. of suspected cases seen
3. No. of lymphatic filariasis cases examined with 4. No. acute clinically diagnosed cases -
manifestation of either lymphedema,hydrocele, Total
elephantiasis - Total
0 5. No. of confirmed acute cases - Total
6. No. of chronic clinically diagnosed
cases - Total
Section F. _________________________
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
 ___JANUARY_____ YEAR: ____2020___

M1
AGPAKO__________________________
_________________________
_________________________

BRGY
________________________
________________________
r submission to RHU/MHC

Services and Deworming for Women of Reproductive Age

Total A3. Deworming Services SES Total

Col. 3) (Col. 1) (Col. 2) (Col. 3)

NHTS Non-NHTS
1. No. of women 20-49 years old given 2 doses of
15 deworming drugs - Total
0 0 0
15
0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
on B. Maternal Care and Services
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

a. Number of pregnant women seen in the

first trimester who have normal BMI -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of pregnant women seen in the first
trimester who have low BMI - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

7. No. of pregnant women given iodine

capsules – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
8. No. of pregnant women given one dose
of deworming tablet - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
9. No. of pregnant women screened for
syphilis - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
10. No. of pregnant women tested positive
for syphilis - Total

0 0 0 0
 • NHTS 0
• Non-NHTS 0
11. No. of pregnant women screened for
Hepatitis B - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
18. No. of deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
19. No. of live births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20a. No. of live births with normal birth
weight - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20b. No. of live births with low birth weight
- Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
20c. No. of live births with unknown birth
weight- Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
21. No. of deliveries attended by skilled
health professionals - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col 3)  (Col. 4)
rks Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

24a. No. of deliveries in public health

facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
24b. No. of deliveries in private health
facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
25. No. of non-facility-based deliveries -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
26a. No. of vaginal deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
26b. No. of deliveries by cesarean
section – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
27a. No. of full-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
27b. No. of pre-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B3. Postpartum and Newborn Care
28. No. of postpartum women together
with their newborn who completed at
least 2 postpartum check-ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
 29. No. of postpartum women who
completed iron with folic acid
supplementation - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
30. No. of postpartum women with
Vitamin A supplementation – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
ction C. Child Care and Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)

epB 3 - Total 0 0 0 11. PCV 1 - Total 0 0

0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 12. PCV 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 13. PCV 3 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 14. MMR 1 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
0 0 0 15. MMR 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
1 (November) - Total 0 0 0 20. Td, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
e 1 (November) - Total 0 0 0 21. MR, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

34. Children 12-23 mos. who completed

1 mos. old seen - Total
MNP supplementation - Total
0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
 1 mos. given 1 dose of
35. Children 0-59 mos. seen - Total
100,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos seen - Total 0 0 0 36. Stunted - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos. old given 2
37. Wasted - Total
tamin A 200,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
1 months old who completed
38. Overweight/Obese - Total
lementation - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS

2-23 mos. seen - Total 39. Normal - Total

0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col. 1) (Col 2) (Col 3)

y/o dewormed (2 doses) - 43. Adolescents, 10-19 y/o dewormed

0 0 0 (2 doses) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

ren 12-59 mos. old 50. Diarrhea cases 0-59 mos. received
itamin A - Total 0 0 0 ORS w/ zinc - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old seen 51. Pneumonia cases 0-59 mos. old
0 0 0 seen - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old 52. Pneumonia cases 0-59 mos. old
ORS - Total 0 0 0 completed treatment - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
 To be submitted Quarterly
ous Disease Prevention and Control Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
miasis Prevention and Control E2. Schistosomiasis Prevention and Control (Con't.)
le 5-65 y/o who ingested 7. No. confirmed chronic cases - Total
- Total 0
nts seen - Total 0 8. No. of confirmed cases (acute and
ected cases seen 0 chronic) - Total
clinically diagnosed cases - 9. No. of cases treated - Total
0
rmed acute cases - Total 0 10. No. of confirmed chronic cases
nic clinically diagnosed referred to a hospital facility - Total
al 0
_________________________________________
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
M1
RGY
Total

(Col. 3)

New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
 0 0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0 0
0
0
0 0
0
0
0 0
0
0
 0 0
0
0

Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
 Total
(Col 4)

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Total
(Col 4)
0
0
0
0
0
0

0
0
0
 0
0
0
0
0
0

0
0
0

0
0
0

0
0
0
Total
(Col 4)

0
0
0

0
0
0

0
0
0

0
0
0
 Total
(Col 4)
't.)

Total
(Col 4)
 FHSIS REPORT for the MONTH: ___JANUARY_____
Name of Barangay: _____TAGPAKO_________
Name of BHS: _______________________
Name of Municipality/City: _______________________
Name of Province: ________________________
Projected Population of the Year: _______________________
For submission to RHU/MHC

Section A. Family Planning Services and Dewor

A1. Modern FP Unmet Need Age Total

(Col. 1) (Col. 2) (Col. 3)

10-14 15-19 20-49
1. No. of WRA with unmet
need for modern FP - Total 5 5 5
15
• NHTS 5 5 5 15
• Non-NHTS 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
a. Female Sterilization/ BTL - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
b. Male Sterilization/ NSV-Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
c. Condom - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d. Pills - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
 d.1 Pills-POP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d.2 Pills-COC - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
e. Injectables (DMPA/ POI) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
f. Implant - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g. IUD (IUD-I and IUD-PP) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.1 IUD-I- Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.2 IUD-PP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
h. NFP-LAM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
i. NFP-BBT - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
j. NFP-CMM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
k. NFP-STM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
l. NFP-SDM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
m. Total Current Users 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
Section B. Maternal Care
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
1. No. of pregnant women w/
at least 4 prenatal check-
ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
2. No. of pregnant women
assessed of their nutritional
status during the 1st tri. -Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
c. No. of pregnant women
seen in the first trimester
who have high BMI - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
3. No. of pregnant women for
the first time given 2 doses of
Td vaccination - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
4. No. of pregnant women for
the 2nd or more times given
at least 3 doses of Td
vaccination (Td2 Plus) - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
5. No. of pregnant women who
completed the dose of iron
with folic acid
supplementation - Total 0 0 0 0
 • NHTS 0
• Non-NHTS 0
6. No. of pregnant women who
completed doses of calcium
carbonate supplementation -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
12. No. of pregnant women
tested positive for Hepatitis
B - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
13. No. of pregnant women
screened for HIV - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
14. No. of pregnant women
tested for CBC or Hgb&Hct
count - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
15. No. of pregnant women
tested for CBC or Hgb&Hct
count diagnosed with
anemia - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
16. No. of pregnant women
screened for gestational
diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
17.   No. of pregnant women
tested positive for
gestational diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col 3)  (Col. 4)
 Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
a. No. of deliveries attended
by a doctor - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by a nurse – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
c. No. of deliveries attended
by midwives - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
22. No. of deliveries attended by
non-skilled health
professionals - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
a. No. of deliveries attended
by Hilot/TBA - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by others - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
23. No. of health facility-based
deliveries - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
27c. No. of fetal deaths - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
27d. No. of abortion/
miscarriage - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0

Section C. Child Care a

Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
C1. Immunization Services
1. CPAB - Total 0 0 0 6. DPT-HiB-HepB 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
2. BCG - Total 0 0 0 7. OPV 1 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
3. HepB, within 24 hours. - Total 0 0 0 8. OPV 2 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
4. DPT-HiB-HepB 1 - Total 0 0 0 9. OPV 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
5. DPT-HiB-HepB 2 - Total 0 0 0 10. IPV - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
16. FIC - Total 0 0 0 18. Td, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
17. CIC - Total 0 0 0 19. MR, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
C2. Nutrition Services
22. Newborns initiated on breastfeeding
immediately after birth lasting to 90 mins - 28. Infants 6-11 mos. old seen - Total
Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
23. Preterm/LBW infants given iron 29. Infants 6-11 mos. given 1 dose of
supplementation - Total 0 0 0 Vitamin A 100,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
24. Infants 6 mos. old seen - Total 0 0 0 30. Children 12-59 mos seen - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
25. Infants exclusively breastfed until 6th month - 31. Children 12-59 mos. old given 2
Total 0 0 0 doses of Vitamin A 200,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
26. Infants 6 mos. old initiated to complementary 32. Infant 6-11 months old who completed
feeding with continued breastfeeding - Total 0 0 0 MNP supplementation - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
27. Infants 6 mos. old initiated to complementary
feeding but no longer or never been breastfed 33. Children 12-23 mos. seen - Total
- Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
0
40. 1-19 y/o given 2 doses of deworming drug - 42. SAC, 5-9 y/o dewormed (2 doses) -
Total 0 0 0 Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
41. PSAC, 1-4 y/o dewormed (2 doses) - Total 0 0 0
• NHTS 0
• Non-NHTS 0
0
44. Sick Infants 6-11 mos. old seen - Total 47. Sick Children 12-59 mos. old
0 0 0 received Vitamin A - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
45. Sick Infants 6-11 mos. old received 48. Diarrhea cases 0-59 months old seen
Vitamin A - Total 0 0 0 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
49. Diarrhea cases 0-59 months old
46. Sick Children 12-59 mos. old seen - Total
0 0 0 received ORS - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
 To be submitted Qua
Section E. Infectious Disease Preven
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
E1. Filariasis Prevention and Control E2. Schistosomiasis Prevention and Contro
1. No. of individual examined for lymphatic 1. No. of people 5-65 y/o who ingested
filariasis - Total 0 MDA drugs - Total
2. No. of individual examined found positive for 2. No. of patients seen - Total
lymphatic filariasis - Total 0 3. No. of suspected cases seen
3. No. of lymphatic filariasis cases examined with 4. No. acute clinically diagnosed cases -
manifestation of either lymphedema,hydrocele, Total
elephantiasis - Total
0 5. No. of confirmed acute cases - Total
6. No. of chronic clinically diagnosed
cases - Total
Section F. _________________________
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
 ___JANUARY_____ YEAR: ____2020___

M1
AGPAKO__________________________
_________________________
_________________________

BRGY
________________________
________________________
r submission to RHU/MHC

Services and Deworming for Women of Reproductive Age

Total A3. Deworming Services SES Total

Col. 3) (Col. 1) (Col. 2) (Col. 3)

NHTS Non-NHTS
1. No. of women 20-49 years old given 2 doses of
15 deworming drugs - Total
0 0 0
15
0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
on B. Maternal Care and Services
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

a. Number of pregnant women seen in the

first trimester who have normal BMI -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of pregnant women seen in the first
trimester who have low BMI - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

7. No. of pregnant women given iodine

capsules – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
8. No. of pregnant women given one dose
of deworming tablet - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
9. No. of pregnant women screened for
syphilis - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
10. No. of pregnant women tested positive
for syphilis - Total

0 0 0 0
 • NHTS 0
• Non-NHTS 0
11. No. of pregnant women screened for
Hepatitis B - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
18. No. of deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
19. No. of live births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20a. No. of live births with normal birth
weight - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20b. No. of live births with low birth weight
- Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
20c. No. of live births with unknown birth
weight- Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
21. No. of deliveries attended by skilled
health professionals - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col 3)  (Col. 4)
rks Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

24a. No. of deliveries in public health

facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
24b. No. of deliveries in private health
facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
25. No. of non-facility-based deliveries -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
26a. No. of vaginal deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
26b. No. of deliveries by cesarean
section – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
27a. No. of full-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
27b. No. of pre-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B3. Postpartum and Newborn Care
28. No. of postpartum women together
with their newborn who completed at
least 2 postpartum check-ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
 29. No. of postpartum women who
completed iron with folic acid
supplementation - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
30. No. of postpartum women with
Vitamin A supplementation – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
ction C. Child Care and Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)

epB 3 - Total 0 0 0 11. PCV 1 - Total 0 0

0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 12. PCV 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 13. PCV 3 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 14. MMR 1 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
0 0 0 15. MMR 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
1 (November) - Total 0 0 0 20. Td, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
e 1 (November) - Total 0 0 0 21. MR, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

34. Children 12-23 mos. who completed

1 mos. old seen - Total
MNP supplementation - Total
0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
 1 mos. given 1 dose of
35. Children 0-59 mos. seen - Total
100,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos seen - Total 0 0 0 36. Stunted - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos. old given 2
37. Wasted - Total
tamin A 200,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
1 months old who completed
38. Overweight/Obese - Total
lementation - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS

2-23 mos. seen - Total 39. Normal - Total

0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col. 1) (Col 2) (Col 3)

y/o dewormed (2 doses) - 43. Adolescents, 10-19 y/o dewormed

0 0 0 (2 doses) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

ren 12-59 mos. old 50. Diarrhea cases 0-59 mos. received
itamin A - Total 0 0 0 ORS w/ zinc - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old seen 51. Pneumonia cases 0-59 mos. old
0 0 0 seen - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old 52. Pneumonia cases 0-59 mos. old
ORS - Total 0 0 0 completed treatment - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
 To be submitted Quarterly
ous Disease Prevention and Control Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
miasis Prevention and Control E2. Schistosomiasis Prevention and Control (Con't.)
le 5-65 y/o who ingested 7. No. confirmed chronic cases - Total
- Total 0
nts seen - Total 0 8. No. of confirmed cases (acute and
ected cases seen 0 chronic) - Total
clinically diagnosed cases - 9. No. of cases treated - Total
0
rmed acute cases - Total 0 10. No. of confirmed chronic cases
nic clinically diagnosed referred to a hospital facility - Total
al 0
_________________________________________
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
M1
RGY
Total

(Col. 3)

New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
 0 0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0 0
0
0
0 0
0
0
0 0
0
0
 0 0
0
0

Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
 Total
(Col 4)

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Total
(Col 4)
0
0
0
0
0
0

0
0
0
 0
0
0
0
0
0

0
0
0

0
0
0

0
0
0
Total
(Col 4)

0
0
0

0
0
0

0
0
0

0
0
0
 Total
(Col 4)
't.)

Total
(Col 4)
 FHSIS REPORT for the MONTH: ___JANUARY_____
Name of Barangay: _____TAGPAKO_________
Name of BHS: _______________________
Name of Municipality/City: _______________________
Name of Province: ________________________
Projected Population of the Year: _______________________
For submission to RHU/MHC

Section A. Family Planning Services and Dewor

A1. Modern FP Unmet Need Age Total

(Col. 1) (Col. 2) (Col. 3)

10-14 15-19 20-49
1. No. of WRA with unmet
need for modern FP - Total 5 5 5
15
• NHTS 5 5 5 15
• Non-NHTS 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
a. Female Sterilization/ BTL - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
b. Male Sterilization/ NSV-Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
c. Condom - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d. Pills - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
 d.1 Pills-POP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d.2 Pills-COC - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
e. Injectables (DMPA/ POI) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
f. Implant - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g. IUD (IUD-I and IUD-PP) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.1 IUD-I- Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.2 IUD-PP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
h. NFP-LAM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
i. NFP-BBT - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
j. NFP-CMM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
k. NFP-STM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
l. NFP-SDM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
m. Total Current Users 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
Section B. Maternal Care
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
1. No. of pregnant women w/
at least 4 prenatal check-
ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
2. No. of pregnant women
assessed of their nutritional
status during the 1st tri. -Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
c. No. of pregnant women
seen in the first trimester
who have high BMI - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
3. No. of pregnant women for
the first time given 2 doses of
Td vaccination - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
4. No. of pregnant women for
the 2nd or more times given
at least 3 doses of Td
vaccination (Td2 Plus) - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
5. No. of pregnant women who
completed the dose of iron
with folic acid
supplementation - Total 0 0 0 0
 • NHTS 0
• Non-NHTS 0
6. No. of pregnant women who
completed doses of calcium
carbonate supplementation -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
12. No. of pregnant women
tested positive for Hepatitis
B - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
13. No. of pregnant women
screened for HIV - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
14. No. of pregnant women
tested for CBC or Hgb&Hct
count - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
15. No. of pregnant women
tested for CBC or Hgb&Hct
count diagnosed with
anemia - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
16. No. of pregnant women
screened for gestational
diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
17.   No. of pregnant women
tested positive for
gestational diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col 3)  (Col. 4)
 Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
a. No. of deliveries attended
by a doctor - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by a nurse – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
c. No. of deliveries attended
by midwives - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
22. No. of deliveries attended by
non-skilled health
professionals - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
a. No. of deliveries attended
by Hilot/TBA - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by others - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
23. No. of health facility-based
deliveries - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
27c. No. of fetal deaths - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
27d. No. of abortion/
miscarriage - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0

Section C. Child Care a

Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
C1. Immunization Services
1. CPAB - Total 0 0 0 6. DPT-HiB-HepB 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
2. BCG - Total 0 0 0 7. OPV 1 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
3. HepB, within 24 hours. - Total 0 0 0 8. OPV 2 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
4. DPT-HiB-HepB 1 - Total 0 0 0 9. OPV 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
5. DPT-HiB-HepB 2 - Total 0 0 0 10. IPV - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
16. FIC - Total 0 0 0 18. Td, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
17. CIC - Total 0 0 0 19. MR, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
C2. Nutrition Services
22. Newborns initiated on breastfeeding
immediately after birth lasting to 90 mins - 28. Infants 6-11 mos. old seen - Total
Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
23. Preterm/LBW infants given iron 29. Infants 6-11 mos. given 1 dose of
supplementation - Total 0 0 0 Vitamin A 100,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
24. Infants 6 mos. old seen - Total 0 0 0 30. Children 12-59 mos seen - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
25. Infants exclusively breastfed until 6th month - 31. Children 12-59 mos. old given 2
Total 0 0 0 doses of Vitamin A 200,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
26. Infants 6 mos. old initiated to complementary 32. Infant 6-11 months old who completed
feeding with continued breastfeeding - Total 0 0 0 MNP supplementation - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
27. Infants 6 mos. old initiated to complementary
feeding but no longer or never been breastfed 33. Children 12-23 mos. seen - Total
- Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
0
40. 1-19 y/o given 2 doses of deworming drug - 42. SAC, 5-9 y/o dewormed (2 doses) -
Total 0 0 0 Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
41. PSAC, 1-4 y/o dewormed (2 doses) - Total 0 0 0
• NHTS 0
• Non-NHTS 0
0
44. Sick Infants 6-11 mos. old seen - Total 47. Sick Children 12-59 mos. old
0 0 0 received Vitamin A - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
45. Sick Infants 6-11 mos. old received 48. Diarrhea cases 0-59 months old seen
Vitamin A - Total 0 0 0 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
49. Diarrhea cases 0-59 months old
46. Sick Children 12-59 mos. old seen - Total
0 0 0 received ORS - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
 To be submitted Qua
Section E. Infectious Disease Preven
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
E1. Filariasis Prevention and Control E2. Schistosomiasis Prevention and Contro
1. No. of individual examined for lymphatic 1. No. of people 5-65 y/o who ingested
filariasis - Total 0 MDA drugs - Total
2. No. of individual examined found positive for 2. No. of patients seen - Total
lymphatic filariasis - Total 0 3. No. of suspected cases seen
3. No. of lymphatic filariasis cases examined with 4. No. acute clinically diagnosed cases -
manifestation of either lymphedema,hydrocele, Total
elephantiasis - Total
0 5. No. of confirmed acute cases - Total
6. No. of chronic clinically diagnosed
cases - Total
Section F. _________________________
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
 ___JANUARY_____ YEAR: ____2020___

M1
AGPAKO__________________________
_________________________
_________________________

BRGY
________________________
________________________
r submission to RHU/MHC

Services and Deworming for Women of Reproductive Age

Total A3. Deworming Services SES Total

Col. 3) (Col. 1) (Col. 2) (Col. 3)

NHTS Non-NHTS
1. No. of women 20-49 years old given 2 doses of
15 deworming drugs - Total
0 0 0
15
0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
on B. Maternal Care and Services
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

a. Number of pregnant women seen in the

first trimester who have normal BMI -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of pregnant women seen in the first
trimester who have low BMI - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

7. No. of pregnant women given iodine

capsules – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
8. No. of pregnant women given one dose
of deworming tablet - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
9. No. of pregnant women screened for
syphilis - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
10. No. of pregnant women tested positive
for syphilis - Total

0 0 0 0
 • NHTS 0
• Non-NHTS 0
11. No. of pregnant women screened for
Hepatitis B - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
18. No. of deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
19. No. of live births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20a. No. of live births with normal birth
weight - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20b. No. of live births with low birth weight
- Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
20c. No. of live births with unknown birth
weight- Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
21. No. of deliveries attended by skilled
health professionals - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col 3)  (Col. 4)
rks Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

24a. No. of deliveries in public health

facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
24b. No. of deliveries in private health
facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
25. No. of non-facility-based deliveries -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
26a. No. of vaginal deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
26b. No. of deliveries by cesarean
section – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
27a. No. of full-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
27b. No. of pre-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B3. Postpartum and Newborn Care
28. No. of postpartum women together
with their newborn who completed at
least 2 postpartum check-ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
 29. No. of postpartum women who
completed iron with folic acid
supplementation - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
30. No. of postpartum women with
Vitamin A supplementation – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
ction C. Child Care and Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)

epB 3 - Total 0 0 0 11. PCV 1 - Total 0 0

0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 12. PCV 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 13. PCV 3 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 14. MMR 1 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
0 0 0 15. MMR 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
1 (November) - Total 0 0 0 20. Td, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
e 1 (November) - Total 0 0 0 21. MR, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

34. Children 12-23 mos. who completed

1 mos. old seen - Total
MNP supplementation - Total
0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
 1 mos. given 1 dose of
35. Children 0-59 mos. seen - Total
100,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos seen - Total 0 0 0 36. Stunted - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos. old given 2
37. Wasted - Total
tamin A 200,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
1 months old who completed
38. Overweight/Obese - Total
lementation - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS

2-23 mos. seen - Total 39. Normal - Total

0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col. 1) (Col 2) (Col 3)

y/o dewormed (2 doses) - 43. Adolescents, 10-19 y/o dewormed

0 0 0 (2 doses) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

ren 12-59 mos. old 50. Diarrhea cases 0-59 mos. received
itamin A - Total 0 0 0 ORS w/ zinc - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old seen 51. Pneumonia cases 0-59 mos. old
0 0 0 seen - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old 52. Pneumonia cases 0-59 mos. old
ORS - Total 0 0 0 completed treatment - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
 To be submitted Quarterly
ous Disease Prevention and Control Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
miasis Prevention and Control E2. Schistosomiasis Prevention and Control (Con't.)
le 5-65 y/o who ingested 7. No. confirmed chronic cases - Total
- Total 0
nts seen - Total 0 8. No. of confirmed cases (acute and
ected cases seen 0 chronic) - Total
clinically diagnosed cases - 9. No. of cases treated - Total
0
rmed acute cases - Total 0 10. No. of confirmed chronic cases
nic clinically diagnosed referred to a hospital facility - Total
al 0
_________________________________________
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
M1
RGY
Total

(Col. 3)

New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
 0 0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0 0
0
0
0 0
0
0
0 0
0
0
 0 0
0
0

Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
 Total
(Col 4)

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Total
(Col 4)
0
0
0
0
0
0

0
0
0
 0
0
0
0
0
0

0
0
0

0
0
0

0
0
0
Total
(Col 4)

0
0
0

0
0
0

0
0
0

0
0
0
 Total
(Col 4)
't.)

Total
(Col 4)
 FHSIS REPORT for the MONTH: ___JANUARY_____
Name of Barangay: _____TAGPAKO_________
Name of BHS: _______________________
Name of Municipality/City: _______________________
Name of Province: ________________________
Projected Population of the Year: _______________________
For submission to RHU/MHC

Section A. Family Planning Services and Dewor

A1. Modern FP Unmet Need Age Total

(Col. 1) (Col. 2) (Col. 3)

10-14 15-19 20-49
1. No. of WRA with unmet
need for modern FP - Total 5 5 5
15
• NHTS 5 5 5 15
• Non-NHTS 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
a. Female Sterilization/ BTL - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
b. Male Sterilization/ NSV-Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
c. Condom - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d. Pills - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
 d.1 Pills-POP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d.2 Pills-COC - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
e. Injectables (DMPA/ POI) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
f. Implant - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g. IUD (IUD-I and IUD-PP) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.1 IUD-I- Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.2 IUD-PP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
h. NFP-LAM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
i. NFP-BBT - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
j. NFP-CMM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
k. NFP-STM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
l. NFP-SDM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
m. Total Current Users 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
Section B. Maternal Care
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
1. No. of pregnant women w/
at least 4 prenatal check-
ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
2. No. of pregnant women
assessed of their nutritional
status during the 1st tri. -Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
c. No. of pregnant women
seen in the first trimester
who have high BMI - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
3. No. of pregnant women for
the first time given 2 doses of
Td vaccination - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
4. No. of pregnant women for
the 2nd or more times given
at least 3 doses of Td
vaccination (Td2 Plus) - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
5. No. of pregnant women who
completed the dose of iron
with folic acid
supplementation - Total 0 0 0 0
 • NHTS 0
• Non-NHTS 0
6. No. of pregnant women who
completed doses of calcium
carbonate supplementation -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
12. No. of pregnant women
tested positive for Hepatitis
B - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
13. No. of pregnant women
screened for HIV - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
14. No. of pregnant women
tested for CBC or Hgb&Hct
count - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
15. No. of pregnant women
tested for CBC or Hgb&Hct
count diagnosed with
anemia - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
16. No. of pregnant women
screened for gestational
diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
17.   No. of pregnant women
tested positive for
gestational diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col 3)  (Col. 4)
 Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
a. No. of deliveries attended
by a doctor - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by a nurse – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
c. No. of deliveries attended
by midwives - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
22. No. of deliveries attended by
non-skilled health
professionals - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
a. No. of deliveries attended
by Hilot/TBA - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by others - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
23. No. of health facility-based
deliveries - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
27c. No. of fetal deaths - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
27d. No. of abortion/
miscarriage - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0

Section C. Child Care a

Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
C1. Immunization Services
1. CPAB - Total 0 0 0 6. DPT-HiB-HepB 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
2. BCG - Total 0 0 0 7. OPV 1 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
3. HepB, within 24 hours. - Total 0 0 0 8. OPV 2 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
4. DPT-HiB-HepB 1 - Total 0 0 0 9. OPV 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
5. DPT-HiB-HepB 2 - Total 0 0 0 10. IPV - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
16. FIC - Total 0 0 0 18. Td, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
17. CIC - Total 0 0 0 19. MR, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
C2. Nutrition Services
22. Newborns initiated on breastfeeding
immediately after birth lasting to 90 mins - 28. Infants 6-11 mos. old seen - Total
Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
23. Preterm/LBW infants given iron 29. Infants 6-11 mos. given 1 dose of
supplementation - Total 0 0 0 Vitamin A 100,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
24. Infants 6 mos. old seen - Total 0 0 0 30. Children 12-59 mos seen - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
25. Infants exclusively breastfed until 6th month - 31. Children 12-59 mos. old given 2
Total 0 0 0 doses of Vitamin A 200,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
26. Infants 6 mos. old initiated to complementary 32. Infant 6-11 months old who completed
feeding with continued breastfeeding - Total 0 0 0 MNP supplementation - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
27. Infants 6 mos. old initiated to complementary
feeding but no longer or never been breastfed 33. Children 12-23 mos. seen - Total
- Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
0
40. 1-19 y/o given 2 doses of deworming drug - 42. SAC, 5-9 y/o dewormed (2 doses) -
Total 0 0 0 Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
41. PSAC, 1-4 y/o dewormed (2 doses) - Total 0 0 0
• NHTS 0
• Non-NHTS 0
0
44. Sick Infants 6-11 mos. old seen - Total 47. Sick Children 12-59 mos. old
0 0 0 received Vitamin A - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
45. Sick Infants 6-11 mos. old received 48. Diarrhea cases 0-59 months old seen
Vitamin A - Total 0 0 0 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
49. Diarrhea cases 0-59 months old
46. Sick Children 12-59 mos. old seen - Total
0 0 0 received ORS - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
 To be submitted Qua
Section E. Infectious Disease Preven
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
E1. Filariasis Prevention and Control E2. Schistosomiasis Prevention and Contro
1. No. of individual examined for lymphatic 1. No. of people 5-65 y/o who ingested
filariasis - Total 0 MDA drugs - Total
2. No. of individual examined found positive for 2. No. of patients seen - Total
lymphatic filariasis - Total 0 3. No. of suspected cases seen
3. No. of lymphatic filariasis cases examined with 4. No. acute clinically diagnosed cases -
manifestation of either lymphedema,hydrocele, Total
elephantiasis - Total
0 5. No. of confirmed acute cases - Total
6. No. of chronic clinically diagnosed
cases - Total
Section F. _________________________
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
 ___JANUARY_____ YEAR: ____2020___

M1
AGPAKO__________________________
_________________________
_________________________

BRGY
________________________
________________________
r submission to RHU/MHC

Services and Deworming for Women of Reproductive Age

Total A3. Deworming Services SES Total

Col. 3) (Col. 1) (Col. 2) (Col. 3)

NHTS Non-NHTS
1. No. of women 20-49 years old given 2 doses of
15 deworming drugs - Total
0 0 0
15
0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
on B. Maternal Care and Services
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

a. Number of pregnant women seen in the

first trimester who have normal BMI -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of pregnant women seen in the first
trimester who have low BMI - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

7. No. of pregnant women given iodine

capsules – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
8. No. of pregnant women given one dose
of deworming tablet - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
9. No. of pregnant women screened for
syphilis - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
10. No. of pregnant women tested positive
for syphilis - Total

0 0 0 0
 • NHTS 0
• Non-NHTS 0
11. No. of pregnant women screened for
Hepatitis B - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
18. No. of deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
19. No. of live births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20a. No. of live births with normal birth
weight - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20b. No. of live births with low birth weight
- Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
20c. No. of live births with unknown birth
weight- Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
21. No. of deliveries attended by skilled
health professionals - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col 3)  (Col. 4)
rks Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

24a. No. of deliveries in public health

facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
24b. No. of deliveries in private health
facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
25. No. of non-facility-based deliveries -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
26a. No. of vaginal deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
26b. No. of deliveries by cesarean
section – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
27a. No. of full-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
27b. No. of pre-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B3. Postpartum and Newborn Care
28. No. of postpartum women together
with their newborn who completed at
least 2 postpartum check-ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
 29. No. of postpartum women who
completed iron with folic acid
supplementation - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
30. No. of postpartum women with
Vitamin A supplementation – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
ction C. Child Care and Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)

epB 3 - Total 0 0 0 11. PCV 1 - Total 0 0

0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 12. PCV 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 13. PCV 3 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 14. MMR 1 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
0 0 0 15. MMR 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
1 (November) - Total 0 0 0 20. Td, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
e 1 (November) - Total 0 0 0 21. MR, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

34. Children 12-23 mos. who completed

1 mos. old seen - Total
MNP supplementation - Total
0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
 1 mos. given 1 dose of
35. Children 0-59 mos. seen - Total
100,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos seen - Total 0 0 0 36. Stunted - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos. old given 2
37. Wasted - Total
tamin A 200,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
1 months old who completed
38. Overweight/Obese - Total
lementation - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS

2-23 mos. seen - Total 39. Normal - Total

0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col. 1) (Col 2) (Col 3)

y/o dewormed (2 doses) - 43. Adolescents, 10-19 y/o dewormed

0 0 0 (2 doses) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

ren 12-59 mos. old 50. Diarrhea cases 0-59 mos. received
itamin A - Total 0 0 0 ORS w/ zinc - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old seen 51. Pneumonia cases 0-59 mos. old
0 0 0 seen - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old 52. Pneumonia cases 0-59 mos. old
ORS - Total 0 0 0 completed treatment - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
 To be submitted Quarterly
ous Disease Prevention and Control Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
miasis Prevention and Control E2. Schistosomiasis Prevention and Control (Con't.)
le 5-65 y/o who ingested 7. No. confirmed chronic cases - Total
- Total 0
nts seen - Total 0 8. No. of confirmed cases (acute and
ected cases seen 0 chronic) - Total
clinically diagnosed cases - 9. No. of cases treated - Total
0
rmed acute cases - Total 0 10. No. of confirmed chronic cases
nic clinically diagnosed referred to a hospital facility - Total
al 0
_________________________________________
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
M1
RGY
Total

(Col. 3)

New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
 0 0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0 0
0
0
0 0
0
0
0 0
0
0
 0 0
0
0

Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
 Total
(Col 4)

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Total
(Col 4)
0
0
0
0
0
0

0
0
0
 0
0
0
0
0
0

0
0
0

0
0
0

0
0
0
Total
(Col 4)

0
0
0

0
0
0

0
0
0

0
0
0
 Total
(Col 4)
't.)

Total
(Col 4)
 FHSIS REPORT for the MONTH: ___JANUARY_____
Name of Barangay: _____TAGPAKO_________
Name of BHS: _______________________
Name of Municipality/City: _______________________
Name of Province: ________________________
Projected Population of the Year: _______________________
For submission to RHU/MHC

Section A. Family Planning Services and Dewor

A1. Modern FP Unmet Need Age Total

(Col. 1) (Col. 2) (Col. 3)

10-14 15-19 20-49
1. No. of WRA with unmet
need for modern FP - Total 5 5 5
15
• NHTS 5 5 5 15
• Non-NHTS 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
a. Female Sterilization/ BTL - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
b. Male Sterilization/ NSV-Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
c. Condom - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d. Pills - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
 d.1 Pills-POP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d.2 Pills-COC - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
e. Injectables (DMPA/ POI) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
f. Implant - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g. IUD (IUD-I and IUD-PP) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.1 IUD-I- Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.2 IUD-PP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
h. NFP-LAM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
i. NFP-BBT - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
j. NFP-CMM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
k. NFP-STM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
l. NFP-SDM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
m. Total Current Users 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
Section B. Maternal Care
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
1. No. of pregnant women w/
at least 4 prenatal check-
ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
2. No. of pregnant women
assessed of their nutritional
status during the 1st tri. -Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
c. No. of pregnant women
seen in the first trimester
who have high BMI - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
3. No. of pregnant women for
the first time given 2 doses of
Td vaccination - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
4. No. of pregnant women for
the 2nd or more times given
at least 3 doses of Td
vaccination (Td2 Plus) - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
5. No. of pregnant women who
completed the dose of iron
with folic acid
supplementation - Total 0 0 0 0
 • NHTS 0
• Non-NHTS 0
6. No. of pregnant women who
completed doses of calcium
carbonate supplementation -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
12. No. of pregnant women
tested positive for Hepatitis
B - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
13. No. of pregnant women
screened for HIV - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
14. No. of pregnant women
tested for CBC or Hgb&Hct
count - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
15. No. of pregnant women
tested for CBC or Hgb&Hct
count diagnosed with
anemia - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
16. No. of pregnant women
screened for gestational
diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
17.   No. of pregnant women
tested positive for
gestational diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col 3)  (Col. 4)
 Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
a. No. of deliveries attended
by a doctor - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by a nurse – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
c. No. of deliveries attended
by midwives - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
22. No. of deliveries attended by
non-skilled health
professionals - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
a. No. of deliveries attended
by Hilot/TBA - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by others - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
23. No. of health facility-based
deliveries - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
27c. No. of fetal deaths - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
27d. No. of abortion/
miscarriage - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0

Section C. Child Care a

Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
C1. Immunization Services
1. CPAB - Total 0 0 0 6. DPT-HiB-HepB 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
2. BCG - Total 0 0 0 7. OPV 1 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
3. HepB, within 24 hours. - Total 0 0 0 8. OPV 2 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
4. DPT-HiB-HepB 1 - Total 0 0 0 9. OPV 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
5. DPT-HiB-HepB 2 - Total 0 0 0 10. IPV - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
16. FIC - Total 0 0 0 18. Td, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
17. CIC - Total 0 0 0 19. MR, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
C2. Nutrition Services
22. Newborns initiated on breastfeeding
immediately after birth lasting to 90 mins - 28. Infants 6-11 mos. old seen - Total
Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
23. Preterm/LBW infants given iron 29. Infants 6-11 mos. given 1 dose of
supplementation - Total 0 0 0 Vitamin A 100,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
24. Infants 6 mos. old seen - Total 0 0 0 30. Children 12-59 mos seen - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
25. Infants exclusively breastfed until 6th month - 31. Children 12-59 mos. old given 2
Total 0 0 0 doses of Vitamin A 200,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
26. Infants 6 mos. old initiated to complementary 32. Infant 6-11 months old who completed
feeding with continued breastfeeding - Total 0 0 0 MNP supplementation - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
27. Infants 6 mos. old initiated to complementary
feeding but no longer or never been breastfed 33. Children 12-23 mos. seen - Total
- Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
0
40. 1-19 y/o given 2 doses of deworming drug - 42. SAC, 5-9 y/o dewormed (2 doses) -
Total 0 0 0 Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
41. PSAC, 1-4 y/o dewormed (2 doses) - Total 0 0 0
• NHTS 0
• Non-NHTS 0
0
44. Sick Infants 6-11 mos. old seen - Total 47. Sick Children 12-59 mos. old
0 0 0 received Vitamin A - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
45. Sick Infants 6-11 mos. old received 48. Diarrhea cases 0-59 months old seen
Vitamin A - Total 0 0 0 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
49. Diarrhea cases 0-59 months old
46. Sick Children 12-59 mos. old seen - Total
0 0 0 received ORS - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
 To be submitted Qua
Section E. Infectious Disease Preven
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
E1. Filariasis Prevention and Control E2. Schistosomiasis Prevention and Contro
1. No. of individual examined for lymphatic 1. No. of people 5-65 y/o who ingested
filariasis - Total 0 MDA drugs - Total
2. No. of individual examined found positive for 2. No. of patients seen - Total
lymphatic filariasis - Total 0 3. No. of suspected cases seen
3. No. of lymphatic filariasis cases examined with 4. No. acute clinically diagnosed cases -
manifestation of either lymphedema,hydrocele, Total
elephantiasis - Total
0 5. No. of confirmed acute cases - Total
6. No. of chronic clinically diagnosed
cases - Total
Section F. _________________________
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
 ___JANUARY_____ YEAR: ____2020___

M1
AGPAKO__________________________
_________________________
_________________________

BRGY
________________________
________________________
r submission to RHU/MHC

Services and Deworming for Women of Reproductive Age

Total A3. Deworming Services SES Total

Col. 3) (Col. 1) (Col. 2) (Col. 3)

NHTS Non-NHTS
1. No. of women 20-49 years old given 2 doses of
15 deworming drugs - Total
0 0 0
15
0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
on B. Maternal Care and Services
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

a. Number of pregnant women seen in the

first trimester who have normal BMI -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of pregnant women seen in the first
trimester who have low BMI - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

7. No. of pregnant women given iodine

capsules – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
8. No. of pregnant women given one dose
of deworming tablet - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
9. No. of pregnant women screened for
syphilis - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
10. No. of pregnant women tested positive
for syphilis - Total

0 0 0 0
 • NHTS 0
• Non-NHTS 0
11. No. of pregnant women screened for
Hepatitis B - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
18. No. of deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
19. No. of live births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20a. No. of live births with normal birth
weight - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20b. No. of live births with low birth weight
- Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
20c. No. of live births with unknown birth
weight- Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
21. No. of deliveries attended by skilled
health professionals - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col 3)  (Col. 4)
rks Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

24a. No. of deliveries in public health

facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
24b. No. of deliveries in private health
facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
25. No. of non-facility-based deliveries -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
26a. No. of vaginal deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
26b. No. of deliveries by cesarean
section – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
27a. No. of full-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
27b. No. of pre-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B3. Postpartum and Newborn Care
28. No. of postpartum women together
with their newborn who completed at
least 2 postpartum check-ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
 29. No. of postpartum women who
completed iron with folic acid
supplementation - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
30. No. of postpartum women with
Vitamin A supplementation – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
ction C. Child Care and Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)

epB 3 - Total 0 0 0 11. PCV 1 - Total 0 0

0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 12. PCV 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 13. PCV 3 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 14. MMR 1 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
0 0 0 15. MMR 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
1 (November) - Total 0 0 0 20. Td, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
e 1 (November) - Total 0 0 0 21. MR, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

34. Children 12-23 mos. who completed

1 mos. old seen - Total
MNP supplementation - Total
0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
 1 mos. given 1 dose of
35. Children 0-59 mos. seen - Total
100,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos seen - Total 0 0 0 36. Stunted - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos. old given 2
37. Wasted - Total
tamin A 200,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
1 months old who completed
38. Overweight/Obese - Total
lementation - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS

2-23 mos. seen - Total 39. Normal - Total

0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col. 1) (Col 2) (Col 3)

y/o dewormed (2 doses) - 43. Adolescents, 10-19 y/o dewormed

0 0 0 (2 doses) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

ren 12-59 mos. old 50. Diarrhea cases 0-59 mos. received
itamin A - Total 0 0 0 ORS w/ zinc - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old seen 51. Pneumonia cases 0-59 mos. old
0 0 0 seen - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old 52. Pneumonia cases 0-59 mos. old
ORS - Total 0 0 0 completed treatment - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
 To be submitted Quarterly
ous Disease Prevention and Control Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
miasis Prevention and Control E2. Schistosomiasis Prevention and Control (Con't.)
le 5-65 y/o who ingested 7. No. confirmed chronic cases - Total
- Total 0
nts seen - Total 0 8. No. of confirmed cases (acute and
ected cases seen 0 chronic) - Total
clinically diagnosed cases - 9. No. of cases treated - Total
0
rmed acute cases - Total 0 10. No. of confirmed chronic cases
nic clinically diagnosed referred to a hospital facility - Total
al 0
_________________________________________
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
M1
RGY
Total

(Col. 3)

New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
 0 0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0 0
0
0
0 0
0
0
0 0
0
0
 0 0
0
0

Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
 Total
(Col 4)

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Total
(Col 4)
0
0
0
0
0
0

0
0
0
 0
0
0
0
0
0

0
0
0

0
0
0

0
0
0
Total
(Col 4)

0
0
0

0
0
0

0
0
0

0
0
0
 Total
(Col 4)
't.)

Total
(Col 4)
 FHSIS REPORT for the MONTH: ___JANUARY_____
Name of Barangay: _____TAGPAKO_________
Name of BHS: _______________________
Name of Municipality/City: _______________________
Name of Province: ________________________
Projected Population of the Year: _______________________
For submission to RHU/MHC

Section A. Family Planning Services and Dewor

A1. Modern FP Unmet Need Age Total

(Col. 1) (Col. 2) (Col. 3)

10-14 15-19 20-49
1. No. of WRA with unmet
need for modern FP - Total 5 5 5
15
• NHTS 5 5 5 15
• Non-NHTS 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
a. Female Sterilization/ BTL - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
b. Male Sterilization/ NSV-Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
c. Condom - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d. Pills - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
 d.1 Pills-POP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d.2 Pills-COC - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
e. Injectables (DMPA/ POI) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
f. Implant - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g. IUD (IUD-I and IUD-PP) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.1 IUD-I- Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.2 IUD-PP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
h. NFP-LAM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
i. NFP-BBT - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
j. NFP-CMM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
k. NFP-STM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
l. NFP-SDM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
m. Total Current Users 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
Section B. Maternal Care
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
1. No. of pregnant women w/
at least 4 prenatal check-
ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
2. No. of pregnant women
assessed of their nutritional
status during the 1st tri. -Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
c. No. of pregnant women
seen in the first trimester
who have high BMI - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
3. No. of pregnant women for
the first time given 2 doses of
Td vaccination - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
4. No. of pregnant women for
the 2nd or more times given
at least 3 doses of Td
vaccination (Td2 Plus) - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
5. No. of pregnant women who
completed the dose of iron
with folic acid
supplementation - Total 0 0 0 0
 • NHTS 0
• Non-NHTS 0
6. No. of pregnant women who
completed doses of calcium
carbonate supplementation -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
12. No. of pregnant women
tested positive for Hepatitis
B - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
13. No. of pregnant women
screened for HIV - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
14. No. of pregnant women
tested for CBC or Hgb&Hct
count - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
15. No. of pregnant women
tested for CBC or Hgb&Hct
count diagnosed with
anemia - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
16. No. of pregnant women
screened for gestational
diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
17.   No. of pregnant women
tested positive for
gestational diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col 3)  (Col. 4)
 Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
a. No. of deliveries attended
by a doctor - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by a nurse – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
c. No. of deliveries attended
by midwives - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
22. No. of deliveries attended by
non-skilled health
professionals - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
a. No. of deliveries attended
by Hilot/TBA - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by others - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
23. No. of health facility-based
deliveries - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
27c. No. of fetal deaths - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
27d. No. of abortion/
miscarriage - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0

Section C. Child Care a

Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
C1. Immunization Services
1. CPAB - Total 0 0 0 6. DPT-HiB-HepB 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
2. BCG - Total 0 0 0 7. OPV 1 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
3. HepB, within 24 hours. - Total 0 0 0 8. OPV 2 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
4. DPT-HiB-HepB 1 - Total 0 0 0 9. OPV 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
5. DPT-HiB-HepB 2 - Total 0 0 0 10. IPV - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
16. FIC - Total 0 0 0 18. Td, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
17. CIC - Total 0 0 0 19. MR, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
C2. Nutrition Services
22. Newborns initiated on breastfeeding
immediately after birth lasting to 90 mins - 28. Infants 6-11 mos. old seen - Total
Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
23. Preterm/LBW infants given iron 29. Infants 6-11 mos. given 1 dose of
supplementation - Total 0 0 0 Vitamin A 100,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
24. Infants 6 mos. old seen - Total 0 0 0 30. Children 12-59 mos seen - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
25. Infants exclusively breastfed until 6th month - 31. Children 12-59 mos. old given 2
Total 0 0 0 doses of Vitamin A 200,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
26. Infants 6 mos. old initiated to complementary 32. Infant 6-11 months old who completed
feeding with continued breastfeeding - Total 0 0 0 MNP supplementation - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
27. Infants 6 mos. old initiated to complementary
feeding but no longer or never been breastfed 33. Children 12-23 mos. seen - Total
- Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
0
40. 1-19 y/o given 2 doses of deworming drug - 42. SAC, 5-9 y/o dewormed (2 doses) -
Total 0 0 0 Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
41. PSAC, 1-4 y/o dewormed (2 doses) - Total 0 0 0
• NHTS 0
• Non-NHTS 0
0
44. Sick Infants 6-11 mos. old seen - Total 47. Sick Children 12-59 mos. old
0 0 0 received Vitamin A - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
45. Sick Infants 6-11 mos. old received 48. Diarrhea cases 0-59 months old seen
Vitamin A - Total 0 0 0 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
49. Diarrhea cases 0-59 months old
46. Sick Children 12-59 mos. old seen - Total
0 0 0 received ORS - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
 To be submitted Qua
Section E. Infectious Disease Preven
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
E1. Filariasis Prevention and Control E2. Schistosomiasis Prevention and Contro
1. No. of individual examined for lymphatic 1. No. of people 5-65 y/o who ingested
filariasis - Total 0 MDA drugs - Total
2. No. of individual examined found positive for 2. No. of patients seen - Total
lymphatic filariasis - Total 0 3. No. of suspected cases seen
3. No. of lymphatic filariasis cases examined with 4. No. acute clinically diagnosed cases -
manifestation of either lymphedema,hydrocele, Total
elephantiasis - Total
0 5. No. of confirmed acute cases - Total
6. No. of chronic clinically diagnosed
cases - Total
Section F. _________________________
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
 ___JANUARY_____ YEAR: ____2020___

M1
AGPAKO__________________________
_________________________
_________________________

BRGY
________________________
________________________
r submission to RHU/MHC

Services and Deworming for Women of Reproductive Age

Total A3. Deworming Services SES Total

Col. 3) (Col. 1) (Col. 2) (Col. 3)

NHTS Non-NHTS
1. No. of women 20-49 years old given 2 doses of
15 deworming drugs - Total
0 0 0
15
0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
on B. Maternal Care and Services
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

a. Number of pregnant women seen in the

first trimester who have normal BMI -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of pregnant women seen in the first
trimester who have low BMI - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

7. No. of pregnant women given iodine

capsules – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
8. No. of pregnant women given one dose
of deworming tablet - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
9. No. of pregnant women screened for
syphilis - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
10. No. of pregnant women tested positive
for syphilis - Total

0 0 0 0
 • NHTS 0
• Non-NHTS 0
11. No. of pregnant women screened for
Hepatitis B - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
18. No. of deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
19. No. of live births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20a. No. of live births with normal birth
weight - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20b. No. of live births with low birth weight
- Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
20c. No. of live births with unknown birth
weight- Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
21. No. of deliveries attended by skilled
health professionals - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col 3)  (Col. 4)
rks Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

24a. No. of deliveries in public health

facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
24b. No. of deliveries in private health
facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
25. No. of non-facility-based deliveries -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
26a. No. of vaginal deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
26b. No. of deliveries by cesarean
section – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
27a. No. of full-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
27b. No. of pre-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B3. Postpartum and Newborn Care
28. No. of postpartum women together
with their newborn who completed at
least 2 postpartum check-ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
 29. No. of postpartum women who
completed iron with folic acid
supplementation - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
30. No. of postpartum women with
Vitamin A supplementation – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
ction C. Child Care and Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)

epB 3 - Total 0 0 0 11. PCV 1 - Total 0 0

0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 12. PCV 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 13. PCV 3 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 14. MMR 1 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
0 0 0 15. MMR 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
1 (November) - Total 0 0 0 20. Td, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
e 1 (November) - Total 0 0 0 21. MR, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

34. Children 12-23 mos. who completed

1 mos. old seen - Total
MNP supplementation - Total
0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
 1 mos. given 1 dose of
35. Children 0-59 mos. seen - Total
100,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos seen - Total 0 0 0 36. Stunted - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos. old given 2
37. Wasted - Total
tamin A 200,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
1 months old who completed
38. Overweight/Obese - Total
lementation - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS

2-23 mos. seen - Total 39. Normal - Total

0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col. 1) (Col 2) (Col 3)

y/o dewormed (2 doses) - 43. Adolescents, 10-19 y/o dewormed

0 0 0 (2 doses) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

ren 12-59 mos. old 50. Diarrhea cases 0-59 mos. received
itamin A - Total 0 0 0 ORS w/ zinc - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old seen 51. Pneumonia cases 0-59 mos. old
0 0 0 seen - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old 52. Pneumonia cases 0-59 mos. old
ORS - Total 0 0 0 completed treatment - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
 To be submitted Quarterly
ous Disease Prevention and Control Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
miasis Prevention and Control E2. Schistosomiasis Prevention and Control (Con't.)
le 5-65 y/o who ingested 7. No. confirmed chronic cases - Total
- Total 0
nts seen - Total 0 8. No. of confirmed cases (acute and
ected cases seen 0 chronic) - Total
clinically diagnosed cases - 9. No. of cases treated - Total
0
rmed acute cases - Total 0 10. No. of confirmed chronic cases
nic clinically diagnosed referred to a hospital facility - Total
al 0
_________________________________________
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
M1
RGY
Total

(Col. 3)

New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
 0 0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0 0
0
0
0 0
0
0
0 0
0
0
 0 0
0
0

Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
 Total
(Col 4)

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Total
(Col 4)
0
0
0
0
0
0

0
0
0
 0
0
0
0
0
0

0
0
0

0
0
0

0
0
0
Total
(Col 4)

0
0
0

0
0
0

0
0
0

0
0
0
 Total
(Col 4)
't.)

Total
(Col 4)
 FHSIS REPORT for the MONTH: ___JANUARY_____
Name of Barangay: _____TAGPAKO_________
Name of BHS: _______________________
Name of Municipality/City: _______________________
Name of Province: ________________________
Projected Population of the Year: _______________________
For submission to RHU/MHC

Section A. Family Planning Services and Dewor

A1. Modern FP Unmet Need Age Total

(Col. 1) (Col. 2) (Col. 3)

10-14 15-19 20-49
1. No. of WRA with unmet
need for modern FP - Total 5 5 5
15
• NHTS 5 5 5 15
• Non-NHTS 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
a. Female Sterilization/ BTL - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
b. Male Sterilization/ NSV-Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
c. Condom - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d. Pills - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
 d.1 Pills-POP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d.2 Pills-COC - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
e. Injectables (DMPA/ POI) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
f. Implant - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g. IUD (IUD-I and IUD-PP) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.1 IUD-I- Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.2 IUD-PP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
h. NFP-LAM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
i. NFP-BBT - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
j. NFP-CMM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
k. NFP-STM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
l. NFP-SDM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
m. Total Current Users 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
Section B. Maternal Care
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
1. No. of pregnant women w/
at least 4 prenatal check-
ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
2. No. of pregnant women
assessed of their nutritional
status during the 1st tri. -Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
c. No. of pregnant women
seen in the first trimester
who have high BMI - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
3. No. of pregnant women for
the first time given 2 doses of
Td vaccination - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
4. No. of pregnant women for
the 2nd or more times given
at least 3 doses of Td
vaccination (Td2 Plus) - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
5. No. of pregnant women who
completed the dose of iron
with folic acid
supplementation - Total 0 0 0 0
 • NHTS 0
• Non-NHTS 0
6. No. of pregnant women who
completed doses of calcium
carbonate supplementation -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
12. No. of pregnant women
tested positive for Hepatitis
B - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
13. No. of pregnant women
screened for HIV - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
14. No. of pregnant women
tested for CBC or Hgb&Hct
count - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
15. No. of pregnant women
tested for CBC or Hgb&Hct
count diagnosed with
anemia - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
16. No. of pregnant women
screened for gestational
diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
17.   No. of pregnant women
tested positive for
gestational diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col 3)  (Col. 4)
 Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
a. No. of deliveries attended
by a doctor - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by a nurse – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
c. No. of deliveries attended
by midwives - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
22. No. of deliveries attended by
non-skilled health
professionals - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
a. No. of deliveries attended
by Hilot/TBA - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by others - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
23. No. of health facility-based
deliveries - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
27c. No. of fetal deaths - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
27d. No. of abortion/
miscarriage - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0

Section C. Child Care a

Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
C1. Immunization Services
1. CPAB - Total 0 0 0 6. DPT-HiB-HepB 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
2. BCG - Total 0 0 0 7. OPV 1 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
3. HepB, within 24 hours. - Total 0 0 0 8. OPV 2 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
4. DPT-HiB-HepB 1 - Total 0 0 0 9. OPV 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
5. DPT-HiB-HepB 2 - Total 0 0 0 10. IPV - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
16. FIC - Total 0 0 0 18. Td, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
17. CIC - Total 0 0 0 19. MR, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
C2. Nutrition Services
22. Newborns initiated on breastfeeding
immediately after birth lasting to 90 mins - 28. Infants 6-11 mos. old seen - Total
Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
23. Preterm/LBW infants given iron 29. Infants 6-11 mos. given 1 dose of
supplementation - Total 0 0 0 Vitamin A 100,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
24. Infants 6 mos. old seen - Total 0 0 0 30. Children 12-59 mos seen - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
25. Infants exclusively breastfed until 6th month - 31. Children 12-59 mos. old given 2
Total 0 0 0 doses of Vitamin A 200,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
26. Infants 6 mos. old initiated to complementary 32. Infant 6-11 months old who completed
feeding with continued breastfeeding - Total 0 0 0 MNP supplementation - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
27. Infants 6 mos. old initiated to complementary
feeding but no longer or never been breastfed 33. Children 12-23 mos. seen - Total
- Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
0
40. 1-19 y/o given 2 doses of deworming drug - 42. SAC, 5-9 y/o dewormed (2 doses) -
Total 0 0 0 Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
41. PSAC, 1-4 y/o dewormed (2 doses) - Total 0 0 0
• NHTS 0
• Non-NHTS 0
0
44. Sick Infants 6-11 mos. old seen - Total 47. Sick Children 12-59 mos. old
0 0 0 received Vitamin A - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
45. Sick Infants 6-11 mos. old received 48. Diarrhea cases 0-59 months old seen
Vitamin A - Total 0 0 0 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
49. Diarrhea cases 0-59 months old
46. Sick Children 12-59 mos. old seen - Total
0 0 0 received ORS - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
 To be submitted Qua
Section E. Infectious Disease Preven
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
E1. Filariasis Prevention and Control E2. Schistosomiasis Prevention and Contro
1. No. of individual examined for lymphatic 1. No. of people 5-65 y/o who ingested
filariasis - Total 0 MDA drugs - Total
2. No. of individual examined found positive for 2. No. of patients seen - Total
lymphatic filariasis - Total 0 3. No. of suspected cases seen
3. No. of lymphatic filariasis cases examined with 4. No. acute clinically diagnosed cases -
manifestation of either lymphedema,hydrocele, Total
elephantiasis - Total
0 5. No. of confirmed acute cases - Total
6. No. of chronic clinically diagnosed
cases - Total
Section F. _________________________
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
 ___JANUARY_____ YEAR: ____2020___

M1
AGPAKO__________________________
_________________________
_________________________

BRGY
________________________
________________________
r submission to RHU/MHC

Services and Deworming for Women of Reproductive Age

Total A3. Deworming Services SES Total

Col. 3) (Col. 1) (Col. 2) (Col. 3)

NHTS Non-NHTS
1. No. of women 20-49 years old given 2 doses of
15 deworming drugs - Total
0 0 0
15
0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
on B. Maternal Care and Services
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

a. Number of pregnant women seen in the

first trimester who have normal BMI -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of pregnant women seen in the first
trimester who have low BMI - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

7. No. of pregnant women given iodine

capsules – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
8. No. of pregnant women given one dose
of deworming tablet - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
9. No. of pregnant women screened for
syphilis - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
10. No. of pregnant women tested positive
for syphilis - Total

0 0 0 0
 • NHTS 0
• Non-NHTS 0
11. No. of pregnant women screened for
Hepatitis B - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
18. No. of deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
19. No. of live births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20a. No. of live births with normal birth
weight - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20b. No. of live births with low birth weight
- Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
20c. No. of live births with unknown birth
weight- Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
21. No. of deliveries attended by skilled
health professionals - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col 3)  (Col. 4)
rks Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

24a. No. of deliveries in public health

facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
24b. No. of deliveries in private health
facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
25. No. of non-facility-based deliveries -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
26a. No. of vaginal deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
26b. No. of deliveries by cesarean
section – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
27a. No. of full-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
27b. No. of pre-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B3. Postpartum and Newborn Care
28. No. of postpartum women together
with their newborn who completed at
least 2 postpartum check-ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
 29. No. of postpartum women who
completed iron with folic acid
supplementation - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
30. No. of postpartum women with
Vitamin A supplementation – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
ction C. Child Care and Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)

epB 3 - Total 0 0 0 11. PCV 1 - Total 0 0

0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 12. PCV 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 13. PCV 3 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 14. MMR 1 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
0 0 0 15. MMR 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
1 (November) - Total 0 0 0 20. Td, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
e 1 (November) - Total 0 0 0 21. MR, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

34. Children 12-23 mos. who completed

1 mos. old seen - Total
MNP supplementation - Total
0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
 1 mos. given 1 dose of
35. Children 0-59 mos. seen - Total
100,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos seen - Total 0 0 0 36. Stunted - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos. old given 2
37. Wasted - Total
tamin A 200,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
1 months old who completed
38. Overweight/Obese - Total
lementation - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS

2-23 mos. seen - Total 39. Normal - Total

0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col. 1) (Col 2) (Col 3)

y/o dewormed (2 doses) - 43. Adolescents, 10-19 y/o dewormed

0 0 0 (2 doses) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

ren 12-59 mos. old 50. Diarrhea cases 0-59 mos. received
itamin A - Total 0 0 0 ORS w/ zinc - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old seen 51. Pneumonia cases 0-59 mos. old
0 0 0 seen - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old 52. Pneumonia cases 0-59 mos. old
ORS - Total 0 0 0 completed treatment - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
 To be submitted Quarterly
ous Disease Prevention and Control Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
miasis Prevention and Control E2. Schistosomiasis Prevention and Control (Con't.)
le 5-65 y/o who ingested 7. No. confirmed chronic cases - Total
- Total 0
nts seen - Total 0 8. No. of confirmed cases (acute and
ected cases seen 0 chronic) - Total
clinically diagnosed cases - 9. No. of cases treated - Total
0
rmed acute cases - Total 0 10. No. of confirmed chronic cases
nic clinically diagnosed referred to a hospital facility - Total
al 0
_________________________________________
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
M1
RGY
Total

(Col. 3)

New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
 0 0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0 0
0
0
0 0
0
0
0 0
0
0
 0 0
0
0

Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
 Total
(Col 4)

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Total
(Col 4)
0
0
0
0
0
0

0
0
0
 0
0
0
0
0
0

0
0
0

0
0
0

0
0
0
Total
(Col 4)

0
0
0

0
0
0

0
0
0

0
0
0
 Total
(Col 4)
't.)

Total
(Col 4)
 FHSIS REPORT for the MONTH: ___JANUARY_____
Name of Barangay: _____TAGPAKO_________
Name of BHS: _______________________
Name of Municipality/City: _______________________
Name of Province: ________________________
Projected Population of the Year: _______________________
For submission to RHU/MHC

Section A. Family Planning Services and Dewor

A1. Modern FP Unmet Need Age Total

(Col. 1) (Col. 2) (Col. 3)

10-14 15-19 20-49
1. No. of WRA with unmet
need for modern FP - Total 5 5 5
15
• NHTS 5 5 5 15
• Non-NHTS 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
a. Female Sterilization/ BTL - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
b. Male Sterilization/ NSV-Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
c. Condom - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d. Pills - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
 d.1 Pills-POP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d.2 Pills-COC - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
e. Injectables (DMPA/ POI) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
f. Implant - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g. IUD (IUD-I and IUD-PP) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.1 IUD-I- Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.2 IUD-PP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
h. NFP-LAM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
i. NFP-BBT - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
j. NFP-CMM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
k. NFP-STM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
l. NFP-SDM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
m. Total Current Users 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
Section B. Maternal Care
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
1. No. of pregnant women w/
at least 4 prenatal check-
ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
2. No. of pregnant women
assessed of their nutritional
status during the 1st tri. -Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
c. No. of pregnant women
seen in the first trimester
who have high BMI - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
3. No. of pregnant women for
the first time given 2 doses of
Td vaccination - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
4. No. of pregnant women for
the 2nd or more times given
at least 3 doses of Td
vaccination (Td2 Plus) - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
5. No. of pregnant women who
completed the dose of iron
with folic acid
supplementation - Total 0 0 0 0
 • NHTS 0
• Non-NHTS 0
6. No. of pregnant women who
completed doses of calcium
carbonate supplementation -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
12. No. of pregnant women
tested positive for Hepatitis
B - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
13. No. of pregnant women
screened for HIV - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
14. No. of pregnant women
tested for CBC or Hgb&Hct
count - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
15. No. of pregnant women
tested for CBC or Hgb&Hct
count diagnosed with
anemia - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
16. No. of pregnant women
screened for gestational
diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
17.   No. of pregnant women
tested positive for
gestational diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col 3)  (Col. 4)
 Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
a. No. of deliveries attended
by a doctor - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by a nurse – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
c. No. of deliveries attended
by midwives - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
22. No. of deliveries attended by
non-skilled health
professionals - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
a. No. of deliveries attended
by Hilot/TBA - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by others - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
23. No. of health facility-based
deliveries - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
27c. No. of fetal deaths - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
27d. No. of abortion/
miscarriage - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0

Section C. Child Care a

Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
C1. Immunization Services
1. CPAB - Total 0 0 0 6. DPT-HiB-HepB 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
2. BCG - Total 0 0 0 7. OPV 1 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
3. HepB, within 24 hours. - Total 0 0 0 8. OPV 2 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
4. DPT-HiB-HepB 1 - Total 0 0 0 9. OPV 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
5. DPT-HiB-HepB 2 - Total 0 0 0 10. IPV - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
16. FIC - Total 0 0 0 18. Td, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
17. CIC - Total 0 0 0 19. MR, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
C2. Nutrition Services
22. Newborns initiated on breastfeeding
immediately after birth lasting to 90 mins - 28. Infants 6-11 mos. old seen - Total
Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
23. Preterm/LBW infants given iron 29. Infants 6-11 mos. given 1 dose of
supplementation - Total 0 0 0 Vitamin A 100,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
24. Infants 6 mos. old seen - Total 0 0 0 30. Children 12-59 mos seen - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
25. Infants exclusively breastfed until 6th month - 31. Children 12-59 mos. old given 2
Total 0 0 0 doses of Vitamin A 200,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
26. Infants 6 mos. old initiated to complementary 32. Infant 6-11 months old who completed
feeding with continued breastfeeding - Total 0 0 0 MNP supplementation - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
27. Infants 6 mos. old initiated to complementary
feeding but no longer or never been breastfed 33. Children 12-23 mos. seen - Total
- Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
0
40. 1-19 y/o given 2 doses of deworming drug - 42. SAC, 5-9 y/o dewormed (2 doses) -
Total 0 0 0 Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
41. PSAC, 1-4 y/o dewormed (2 doses) - Total 0 0 0
• NHTS 0
• Non-NHTS 0
0
44. Sick Infants 6-11 mos. old seen - Total 47. Sick Children 12-59 mos. old
0 0 0 received Vitamin A - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
45. Sick Infants 6-11 mos. old received 48. Diarrhea cases 0-59 months old seen
Vitamin A - Total 0 0 0 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
49. Diarrhea cases 0-59 months old
46. Sick Children 12-59 mos. old seen - Total
0 0 0 received ORS - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
 To be submitted Qua
Section E. Infectious Disease Preven
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
E1. Filariasis Prevention and Control E2. Schistosomiasis Prevention and Contro
1. No. of individual examined for lymphatic 1. No. of people 5-65 y/o who ingested
filariasis - Total 0 MDA drugs - Total
2. No. of individual examined found positive for 2. No. of patients seen - Total
lymphatic filariasis - Total 0 3. No. of suspected cases seen
3. No. of lymphatic filariasis cases examined with 4. No. acute clinically diagnosed cases -
manifestation of either lymphedema,hydrocele, Total
elephantiasis - Total
0 5. No. of confirmed acute cases - Total
6. No. of chronic clinically diagnosed
cases - Total
Section F. _________________________
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
 ___JANUARY_____ YEAR: ____2020___

M1
AGPAKO__________________________
_________________________
_________________________

BRGY
________________________
________________________
r submission to RHU/MHC

Services and Deworming for Women of Reproductive Age

Total A3. Deworming Services SES Total

Col. 3) (Col. 1) (Col. 2) (Col. 3)

NHTS Non-NHTS
1. No. of women 20-49 years old given 2 doses of
15 deworming drugs - Total
0 0 0
15
0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
on B. Maternal Care and Services
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

a. Number of pregnant women seen in the

first trimester who have normal BMI -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of pregnant women seen in the first
trimester who have low BMI - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

7. No. of pregnant women given iodine

capsules – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
8. No. of pregnant women given one dose
of deworming tablet - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
9. No. of pregnant women screened for
syphilis - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
10. No. of pregnant women tested positive
for syphilis - Total

0 0 0 0
 • NHTS 0
• Non-NHTS 0
11. No. of pregnant women screened for
Hepatitis B - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
18. No. of deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
19. No. of live births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20a. No. of live births with normal birth
weight - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20b. No. of live births with low birth weight
- Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
20c. No. of live births with unknown birth
weight- Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
21. No. of deliveries attended by skilled
health professionals - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col 3)  (Col. 4)
rks Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

24a. No. of deliveries in public health

facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
24b. No. of deliveries in private health
facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
25. No. of non-facility-based deliveries -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
26a. No. of vaginal deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
26b. No. of deliveries by cesarean
section – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
27a. No. of full-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
27b. No. of pre-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B3. Postpartum and Newborn Care
28. No. of postpartum women together
with their newborn who completed at
least 2 postpartum check-ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
 29. No. of postpartum women who
completed iron with folic acid
supplementation - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
30. No. of postpartum women with
Vitamin A supplementation – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
ction C. Child Care and Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)

epB 3 - Total 0 0 0 11. PCV 1 - Total 0 0

0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 12. PCV 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 13. PCV 3 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 14. MMR 1 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
0 0 0 15. MMR 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
1 (November) - Total 0 0 0 20. Td, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
e 1 (November) - Total 0 0 0 21. MR, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

34. Children 12-23 mos. who completed

1 mos. old seen - Total
MNP supplementation - Total
0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
 1 mos. given 1 dose of
35. Children 0-59 mos. seen - Total
100,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos seen - Total 0 0 0 36. Stunted - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos. old given 2
37. Wasted - Total
tamin A 200,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
1 months old who completed
38. Overweight/Obese - Total
lementation - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS

2-23 mos. seen - Total 39. Normal - Total

0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col. 1) (Col 2) (Col 3)

y/o dewormed (2 doses) - 43. Adolescents, 10-19 y/o dewormed

0 0 0 (2 doses) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

ren 12-59 mos. old 50. Diarrhea cases 0-59 mos. received
itamin A - Total 0 0 0 ORS w/ zinc - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old seen 51. Pneumonia cases 0-59 mos. old
0 0 0 seen - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old 52. Pneumonia cases 0-59 mos. old
ORS - Total 0 0 0 completed treatment - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
 To be submitted Quarterly
ous Disease Prevention and Control Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
miasis Prevention and Control E2. Schistosomiasis Prevention and Control (Con't.)
le 5-65 y/o who ingested 7. No. confirmed chronic cases - Total
- Total 0
nts seen - Total 0 8. No. of confirmed cases (acute and
ected cases seen 0 chronic) - Total
clinically diagnosed cases - 9. No. of cases treated - Total
0
rmed acute cases - Total 0 10. No. of confirmed chronic cases
nic clinically diagnosed referred to a hospital facility - Total
al 0
_________________________________________
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
M1
RGY
Total

(Col. 3)

New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
 0 0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0 0
0
0
0 0
0
0
0 0
0
0
 0 0
0
0

Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
 Total
(Col 4)

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Total
(Col 4)
0
0
0
0
0
0

0
0
0
 0
0
0
0
0
0

0
0
0

0
0
0

0
0
0
Total
(Col 4)

0
0
0

0
0
0

0
0
0

0
0
0
 Total
(Col 4)
't.)

Total
(Col 4)
 FHSIS REPORT for the MONTH: ___JANUARY_____
Name of Barangay: _____TAGPAKO_________
Name of BHS: _______________________
Name of Municipality/City: _______________________
Name of Province: ________________________
Projected Population of the Year: _______________________
For submission to RHU/MHC

Section A. Family Planning Services and Dewor

A1. Modern FP Unmet Need Age Total

(Col. 1) (Col. 2) (Col. 3)

10-14 15-19 20-49
1. No. of WRA with unmet
need for modern FP - Total 5 5 5
15
• NHTS 5 5 5 15
• Non-NHTS 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
a. Female Sterilization/ BTL - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
b. Male Sterilization/ NSV-Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
c. Condom - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d. Pills - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
 d.1 Pills-POP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d.2 Pills-COC - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
e. Injectables (DMPA/ POI) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
f. Implant - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g. IUD (IUD-I and IUD-PP) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.1 IUD-I- Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.2 IUD-PP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
h. NFP-LAM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
i. NFP-BBT - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
j. NFP-CMM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
k. NFP-STM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
l. NFP-SDM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
m. Total Current Users 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
Section B. Maternal Care
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
1. No. of pregnant women w/
at least 4 prenatal check-
ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
2. No. of pregnant women
assessed of their nutritional
status during the 1st tri. -Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
c. No. of pregnant women
seen in the first trimester
who have high BMI - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
3. No. of pregnant women for
the first time given 2 doses of
Td vaccination - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
4. No. of pregnant women for
the 2nd or more times given
at least 3 doses of Td
vaccination (Td2 Plus) - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
5. No. of pregnant women who
completed the dose of iron
with folic acid
supplementation - Total 0 0 0 0
 • NHTS 0
• Non-NHTS 0
6. No. of pregnant women who
completed doses of calcium
carbonate supplementation -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
12. No. of pregnant women
tested positive for Hepatitis
B - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
13. No. of pregnant women
screened for HIV - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
14. No. of pregnant women
tested for CBC or Hgb&Hct
count - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
15. No. of pregnant women
tested for CBC or Hgb&Hct
count diagnosed with
anemia - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
16. No. of pregnant women
screened for gestational
diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
17.   No. of pregnant women
tested positive for
gestational diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col 3)  (Col. 4)
 Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
a. No. of deliveries attended
by a doctor - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by a nurse – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
c. No. of deliveries attended
by midwives - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
22. No. of deliveries attended by
non-skilled health
professionals - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
a. No. of deliveries attended
by Hilot/TBA - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by others - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
23. No. of health facility-based
deliveries - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
27c. No. of fetal deaths - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
27d. No. of abortion/
miscarriage - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0

Section C. Child Care a

Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
C1. Immunization Services
1. CPAB - Total 0 0 0 6. DPT-HiB-HepB 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
2. BCG - Total 0 0 0 7. OPV 1 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
3. HepB, within 24 hours. - Total 0 0 0 8. OPV 2 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
4. DPT-HiB-HepB 1 - Total 0 0 0 9. OPV 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
5. DPT-HiB-HepB 2 - Total 0 0 0 10. IPV - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
16. FIC - Total 0 0 0 18. Td, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
17. CIC - Total 0 0 0 19. MR, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
C2. Nutrition Services
22. Newborns initiated on breastfeeding
immediately after birth lasting to 90 mins - 28. Infants 6-11 mos. old seen - Total
Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
23. Preterm/LBW infants given iron 29. Infants 6-11 mos. given 1 dose of
supplementation - Total 0 0 0 Vitamin A 100,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
24. Infants 6 mos. old seen - Total 0 0 0 30. Children 12-59 mos seen - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
25. Infants exclusively breastfed until 6th month - 31. Children 12-59 mos. old given 2
Total 0 0 0 doses of Vitamin A 200,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
26. Infants 6 mos. old initiated to complementary 32. Infant 6-11 months old who completed
feeding with continued breastfeeding - Total 0 0 0 MNP supplementation - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
27. Infants 6 mos. old initiated to complementary
feeding but no longer or never been breastfed 33. Children 12-23 mos. seen - Total
- Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
0
40. 1-19 y/o given 2 doses of deworming drug - 42. SAC, 5-9 y/o dewormed (2 doses) -
Total 0 0 0 Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
41. PSAC, 1-4 y/o dewormed (2 doses) - Total 0 0 0
• NHTS 0
• Non-NHTS 0
0
44. Sick Infants 6-11 mos. old seen - Total 47. Sick Children 12-59 mos. old
0 0 0 received Vitamin A - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
45. Sick Infants 6-11 mos. old received 48. Diarrhea cases 0-59 months old seen
Vitamin A - Total 0 0 0 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
49. Diarrhea cases 0-59 months old
46. Sick Children 12-59 mos. old seen - Total
0 0 0 received ORS - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
 To be submitted Qua
Section E. Infectious Disease Preven
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
E1. Filariasis Prevention and Control E2. Schistosomiasis Prevention and Contro
1. No. of individual examined for lymphatic 1. No. of people 5-65 y/o who ingested
filariasis - Total 0 MDA drugs - Total
2. No. of individual examined found positive for 2. No. of patients seen - Total
lymphatic filariasis - Total 0 3. No. of suspected cases seen
3. No. of lymphatic filariasis cases examined with 4. No. acute clinically diagnosed cases -
manifestation of either lymphedema,hydrocele, Total
elephantiasis - Total
0 5. No. of confirmed acute cases - Total
6. No. of chronic clinically diagnosed
cases - Total
Section F. _________________________
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
 ___JANUARY_____ YEAR: ____2020___

M1
AGPAKO__________________________
_________________________
_________________________

BRGY
________________________
________________________
r submission to RHU/MHC

Services and Deworming for Women of Reproductive Age

Total A3. Deworming Services SES Total

Col. 3) (Col. 1) (Col. 2) (Col. 3)

NHTS Non-NHTS
1. No. of women 20-49 years old given 2 doses of
15 deworming drugs - Total
0 0 0
15
0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
on B. Maternal Care and Services
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

a. Number of pregnant women seen in the

first trimester who have normal BMI -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of pregnant women seen in the first
trimester who have low BMI - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

7. No. of pregnant women given iodine

capsules – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
8. No. of pregnant women given one dose
of deworming tablet - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
9. No. of pregnant women screened for
syphilis - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
10. No. of pregnant women tested positive
for syphilis - Total

0 0 0 0
 • NHTS 0
• Non-NHTS 0
11. No. of pregnant women screened for
Hepatitis B - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
18. No. of deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
19. No. of live births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20a. No. of live births with normal birth
weight - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20b. No. of live births with low birth weight
- Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
20c. No. of live births with unknown birth
weight- Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
21. No. of deliveries attended by skilled
health professionals - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col 3)  (Col. 4)
rks Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

24a. No. of deliveries in public health

facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
24b. No. of deliveries in private health
facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
25. No. of non-facility-based deliveries -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
26a. No. of vaginal deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
26b. No. of deliveries by cesarean
section – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
27a. No. of full-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
27b. No. of pre-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B3. Postpartum and Newborn Care
28. No. of postpartum women together
with their newborn who completed at
least 2 postpartum check-ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
 29. No. of postpartum women who
completed iron with folic acid
supplementation - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
30. No. of postpartum women with
Vitamin A supplementation – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
ction C. Child Care and Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)

epB 3 - Total 0 0 0 11. PCV 1 - Total 0 0

0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 12. PCV 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 13. PCV 3 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 14. MMR 1 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
0 0 0 15. MMR 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
1 (November) - Total 0 0 0 20. Td, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
e 1 (November) - Total 0 0 0 21. MR, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

34. Children 12-23 mos. who completed

1 mos. old seen - Total
MNP supplementation - Total
0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
 1 mos. given 1 dose of
35. Children 0-59 mos. seen - Total
100,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos seen - Total 0 0 0 36. Stunted - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos. old given 2
37. Wasted - Total
tamin A 200,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
1 months old who completed
38. Overweight/Obese - Total
lementation - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS

2-23 mos. seen - Total 39. Normal - Total

0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col. 1) (Col 2) (Col 3)

y/o dewormed (2 doses) - 43. Adolescents, 10-19 y/o dewormed

0 0 0 (2 doses) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

ren 12-59 mos. old 50. Diarrhea cases 0-59 mos. received
itamin A - Total 0 0 0 ORS w/ zinc - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old seen 51. Pneumonia cases 0-59 mos. old
0 0 0 seen - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old 52. Pneumonia cases 0-59 mos. old
ORS - Total 0 0 0 completed treatment - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
 To be submitted Quarterly
ous Disease Prevention and Control Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
miasis Prevention and Control E2. Schistosomiasis Prevention and Control (Con't.)
le 5-65 y/o who ingested 7. No. confirmed chronic cases - Total
- Total 0
nts seen - Total 0 8. No. of confirmed cases (acute and
ected cases seen 0 chronic) - Total
clinically diagnosed cases - 9. No. of cases treated - Total
0
rmed acute cases - Total 0 10. No. of confirmed chronic cases
nic clinically diagnosed referred to a hospital facility - Total
al 0
_________________________________________
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
M1
RGY
Total

(Col. 3)

New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
 0 0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0 0
0
0
0 0
0
0
0 0
0
0
 0 0
0
0

Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
 Total
(Col 4)

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Total
(Col 4)
0
0
0
0
0
0

0
0
0
 0
0
0
0
0
0

0
0
0

0
0
0

0
0
0
Total
(Col 4)

0
0
0

0
0
0

0
0
0

0
0
0
 Total
(Col 4)
't.)

Total
(Col 4)
 FHSIS REPORT for the MONTH: ___JANUARY_____
Name of Barangay: _____TAGPAKO_________
Name of BHS: _______________________
Name of Municipality/City: _______________________
Name of Province: ________________________
Projected Population of the Year: _______________________
For submission to RHU/MHC

Section A. Family Planning Services and Dewor

A1. Modern FP Unmet Need Age Total

(Col. 1) (Col. 2) (Col. 3)

10-14 15-19 20-49
1. No. of WRA with unmet
need for modern FP - Total 5 5 5
15
• NHTS 5 5 5 15
• Non-NHTS 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
a. Female Sterilization/ BTL - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
b. Male Sterilization/ NSV-Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
c. Condom - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d. Pills - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
 d.1 Pills-POP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d.2 Pills-COC - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
e. Injectables (DMPA/ POI) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
f. Implant - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g. IUD (IUD-I and IUD-PP) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.1 IUD-I- Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.2 IUD-PP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
h. NFP-LAM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
i. NFP-BBT - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
j. NFP-CMM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
k. NFP-STM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
l. NFP-SDM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
m. Total Current Users 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
Section B. Maternal Care
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
1. No. of pregnant women w/
at least 4 prenatal check-
ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
2. No. of pregnant women
assessed of their nutritional
status during the 1st tri. -Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
c. No. of pregnant women
seen in the first trimester
who have high BMI - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
3. No. of pregnant women for
the first time given 2 doses of
Td vaccination - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
4. No. of pregnant women for
the 2nd or more times given
at least 3 doses of Td
vaccination (Td2 Plus) - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
5. No. of pregnant women who
completed the dose of iron
with folic acid
supplementation - Total 0 0 0 0
 • NHTS 0
• Non-NHTS 0
6. No. of pregnant women who
completed doses of calcium
carbonate supplementation -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
12. No. of pregnant women
tested positive for Hepatitis
B - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
13. No. of pregnant women
screened for HIV - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
14. No. of pregnant women
tested for CBC or Hgb&Hct
count - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
15. No. of pregnant women
tested for CBC or Hgb&Hct
count diagnosed with
anemia - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
16. No. of pregnant women
screened for gestational
diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
17.   No. of pregnant women
tested positive for
gestational diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col 3)  (Col. 4)
 Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
a. No. of deliveries attended
by a doctor - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by a nurse – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
c. No. of deliveries attended
by midwives - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
22. No. of deliveries attended by
non-skilled health
professionals - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
a. No. of deliveries attended
by Hilot/TBA - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by others - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
23. No. of health facility-based
deliveries - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
27c. No. of fetal deaths - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
27d. No. of abortion/
miscarriage - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0

Section C. Child Care a

Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
C1. Immunization Services
1. CPAB - Total 0 0 0 6. DPT-HiB-HepB 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
2. BCG - Total 0 0 0 7. OPV 1 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
3. HepB, within 24 hours. - Total 0 0 0 8. OPV 2 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
4. DPT-HiB-HepB 1 - Total 0 0 0 9. OPV 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
5. DPT-HiB-HepB 2 - Total 0 0 0 10. IPV - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
16. FIC - Total 0 0 0 18. Td, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
17. CIC - Total 0 0 0 19. MR, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
C2. Nutrition Services
22. Newborns initiated on breastfeeding
immediately after birth lasting to 90 mins - 28. Infants 6-11 mos. old seen - Total
Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
23. Preterm/LBW infants given iron 29. Infants 6-11 mos. given 1 dose of
supplementation - Total 0 0 0 Vitamin A 100,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
24. Infants 6 mos. old seen - Total 0 0 0 30. Children 12-59 mos seen - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
25. Infants exclusively breastfed until 6th month - 31. Children 12-59 mos. old given 2
Total 0 0 0 doses of Vitamin A 200,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
26. Infants 6 mos. old initiated to complementary 32. Infant 6-11 months old who completed
feeding with continued breastfeeding - Total 0 0 0 MNP supplementation - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
27. Infants 6 mos. old initiated to complementary
feeding but no longer or never been breastfed 33. Children 12-23 mos. seen - Total
- Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
0
40. 1-19 y/o given 2 doses of deworming drug - 42. SAC, 5-9 y/o dewormed (2 doses) -
Total 0 0 0 Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
41. PSAC, 1-4 y/o dewormed (2 doses) - Total 0 0 0
• NHTS 0
• Non-NHTS 0
0
44. Sick Infants 6-11 mos. old seen - Total 47. Sick Children 12-59 mos. old
0 0 0 received Vitamin A - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
45. Sick Infants 6-11 mos. old received 48. Diarrhea cases 0-59 months old seen
Vitamin A - Total 0 0 0 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
49. Diarrhea cases 0-59 months old
46. Sick Children 12-59 mos. old seen - Total
0 0 0 received ORS - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
 To be submitted Qua
Section E. Infectious Disease Preven
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
E1. Filariasis Prevention and Control E2. Schistosomiasis Prevention and Contro
1. No. of individual examined for lymphatic 1. No. of people 5-65 y/o who ingested
filariasis - Total 0 MDA drugs - Total
2. No. of individual examined found positive for 2. No. of patients seen - Total
lymphatic filariasis - Total 0 3. No. of suspected cases seen
3. No. of lymphatic filariasis cases examined with 4. No. acute clinically diagnosed cases -
manifestation of either lymphedema,hydrocele, Total
elephantiasis - Total
0 5. No. of confirmed acute cases - Total
6. No. of chronic clinically diagnosed
cases - Total
Section F. _________________________
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
 ___JANUARY_____ YEAR: ____2020___

M1
AGPAKO__________________________
_________________________
_________________________

BRGY
________________________
________________________
r submission to RHU/MHC

Services and Deworming for Women of Reproductive Age

Total A3. Deworming Services SES Total

Col. 3) (Col. 1) (Col. 2) (Col. 3)

NHTS Non-NHTS
1. No. of women 20-49 years old given 2 doses of
15 deworming drugs - Total
0 0 0
15
0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
on B. Maternal Care and Services
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

a. Number of pregnant women seen in the

first trimester who have normal BMI -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of pregnant women seen in the first
trimester who have low BMI - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

7. No. of pregnant women given iodine

capsules – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
8. No. of pregnant women given one dose
of deworming tablet - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
9. No. of pregnant women screened for
syphilis - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
10. No. of pregnant women tested positive
for syphilis - Total

0 0 0 0
 • NHTS 0
• Non-NHTS 0
11. No. of pregnant women screened for
Hepatitis B - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
18. No. of deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
19. No. of live births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20a. No. of live births with normal birth
weight - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20b. No. of live births with low birth weight
- Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
20c. No. of live births with unknown birth
weight- Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
21. No. of deliveries attended by skilled
health professionals - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col 3)  (Col. 4)
rks Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

24a. No. of deliveries in public health

facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
24b. No. of deliveries in private health
facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
25. No. of non-facility-based deliveries -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
26a. No. of vaginal deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
26b. No. of deliveries by cesarean
section – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
27a. No. of full-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
27b. No. of pre-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B3. Postpartum and Newborn Care
28. No. of postpartum women together
with their newborn who completed at
least 2 postpartum check-ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
 29. No. of postpartum women who
completed iron with folic acid
supplementation - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
30. No. of postpartum women with
Vitamin A supplementation – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
ction C. Child Care and Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)

epB 3 - Total 0 0 0 11. PCV 1 - Total 0 0

0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 12. PCV 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 13. PCV 3 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 14. MMR 1 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
0 0 0 15. MMR 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
1 (November) - Total 0 0 0 20. Td, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
e 1 (November) - Total 0 0 0 21. MR, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

34. Children 12-23 mos. who completed

1 mos. old seen - Total
MNP supplementation - Total
0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
 1 mos. given 1 dose of
35. Children 0-59 mos. seen - Total
100,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos seen - Total 0 0 0 36. Stunted - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos. old given 2
37. Wasted - Total
tamin A 200,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
1 months old who completed
38. Overweight/Obese - Total
lementation - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS

2-23 mos. seen - Total 39. Normal - Total

0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col. 1) (Col 2) (Col 3)

y/o dewormed (2 doses) - 43. Adolescents, 10-19 y/o dewormed

0 0 0 (2 doses) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

ren 12-59 mos. old 50. Diarrhea cases 0-59 mos. received
itamin A - Total 0 0 0 ORS w/ zinc - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old seen 51. Pneumonia cases 0-59 mos. old
0 0 0 seen - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old 52. Pneumonia cases 0-59 mos. old
ORS - Total 0 0 0 completed treatment - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
 To be submitted Quarterly
ous Disease Prevention and Control Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
miasis Prevention and Control E2. Schistosomiasis Prevention and Control (Con't.)
le 5-65 y/o who ingested 7. No. confirmed chronic cases - Total
- Total 0
nts seen - Total 0 8. No. of confirmed cases (acute and
ected cases seen 0 chronic) - Total
clinically diagnosed cases - 9. No. of cases treated - Total
0
rmed acute cases - Total 0 10. No. of confirmed chronic cases
nic clinically diagnosed referred to a hospital facility - Total
al 0
_________________________________________
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
M1
RGY
Total

(Col. 3)

New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
 0 0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0 0
0
0
0 0
0
0
0 0
0
0
 0 0
0
0

Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
 Total
(Col 4)

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Total
(Col 4)
0
0
0
0
0
0

0
0
0
 0
0
0
0
0
0

0
0
0

0
0
0

0
0
0
Total
(Col 4)

0
0
0

0
0
0

0
0
0

0
0
0
 Total
(Col 4)
't.)

Total
(Col 4)
 FHSIS REPORT for the MONTH: ___JANUARY_____
Name of Barangay: _____TAGPAKO_________
Name of BHS: _______________________
Name of Municipality/City: _______________________
Name of Province: ________________________
Projected Population of the Year: _______________________
For submission to RHU/MHC

Section A. Family Planning Services and Dewor

A1. Modern FP Unmet Need Age Total

(Col. 1) (Col. 2) (Col. 3)

10-14 15-19 20-49
1. No. of WRA with unmet
need for modern FP - Total 5 5 5
15
• NHTS 5 5 5 15
• Non-NHTS 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
a. Female Sterilization/ BTL - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
b. Male Sterilization/ NSV-Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
c. Condom - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d. Pills - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
 d.1 Pills-POP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d.2 Pills-COC - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
e. Injectables (DMPA/ POI) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
f. Implant - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g. IUD (IUD-I and IUD-PP) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.1 IUD-I- Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.2 IUD-PP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
h. NFP-LAM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
i. NFP-BBT - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
j. NFP-CMM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
k. NFP-STM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
l. NFP-SDM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
m. Total Current Users 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
Section B. Maternal Care
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
1. No. of pregnant women w/
at least 4 prenatal check-
ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
2. No. of pregnant women
assessed of their nutritional
status during the 1st tri. -Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
c. No. of pregnant women
seen in the first trimester
who have high BMI - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
3. No. of pregnant women for
the first time given 2 doses of
Td vaccination - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
4. No. of pregnant women for
the 2nd or more times given
at least 3 doses of Td
vaccination (Td2 Plus) - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
5. No. of pregnant women who
completed the dose of iron
with folic acid
supplementation - Total 0 0 0 0
 • NHTS 0
• Non-NHTS 0
6. No. of pregnant women who
completed doses of calcium
carbonate supplementation -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
12. No. of pregnant women
tested positive for Hepatitis
B - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
13. No. of pregnant women
screened for HIV - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
14. No. of pregnant women
tested for CBC or Hgb&Hct
count - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
15. No. of pregnant women
tested for CBC or Hgb&Hct
count diagnosed with
anemia - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
16. No. of pregnant women
screened for gestational
diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
17.   No. of pregnant women
tested positive for
gestational diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col 3)  (Col. 4)
 Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
a. No. of deliveries attended
by a doctor - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by a nurse – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
c. No. of deliveries attended
by midwives - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
22. No. of deliveries attended by
non-skilled health
professionals - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
a. No. of deliveries attended
by Hilot/TBA - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by others - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
23. No. of health facility-based
deliveries - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
27c. No. of fetal deaths - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
27d. No. of abortion/
miscarriage - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0

Section C. Child Care a

Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
C1. Immunization Services
1. CPAB - Total 0 0 0 6. DPT-HiB-HepB 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
2. BCG - Total 0 0 0 7. OPV 1 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
3. HepB, within 24 hours. - Total 0 0 0 8. OPV 2 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
4. DPT-HiB-HepB 1 - Total 0 0 0 9. OPV 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
5. DPT-HiB-HepB 2 - Total 0 0 0 10. IPV - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
16. FIC - Total 0 0 0 18. Td, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
17. CIC - Total 0 0 0 19. MR, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
C2. Nutrition Services
22. Newborns initiated on breastfeeding
immediately after birth lasting to 90 mins - 28. Infants 6-11 mos. old seen - Total
Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
23. Preterm/LBW infants given iron 29. Infants 6-11 mos. given 1 dose of
supplementation - Total 0 0 0 Vitamin A 100,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
24. Infants 6 mos. old seen - Total 0 0 0 30. Children 12-59 mos seen - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
25. Infants exclusively breastfed until 6th month - 31. Children 12-59 mos. old given 2
Total 0 0 0 doses of Vitamin A 200,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
26. Infants 6 mos. old initiated to complementary 32. Infant 6-11 months old who completed
feeding with continued breastfeeding - Total 0 0 0 MNP supplementation - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
27. Infants 6 mos. old initiated to complementary
feeding but no longer or never been breastfed 33. Children 12-23 mos. seen - Total
- Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
0
40. 1-19 y/o given 2 doses of deworming drug - 42. SAC, 5-9 y/o dewormed (2 doses) -
Total 0 0 0 Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
41. PSAC, 1-4 y/o dewormed (2 doses) - Total 0 0 0
• NHTS 0
• Non-NHTS 0
0
44. Sick Infants 6-11 mos. old seen - Total 47. Sick Children 12-59 mos. old
0 0 0 received Vitamin A - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
45. Sick Infants 6-11 mos. old received 48. Diarrhea cases 0-59 months old seen
Vitamin A - Total 0 0 0 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
49. Diarrhea cases 0-59 months old
46. Sick Children 12-59 mos. old seen - Total
0 0 0 received ORS - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
 To be submitted Qua
Section E. Infectious Disease Preven
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
E1. Filariasis Prevention and Control E2. Schistosomiasis Prevention and Contro
1. No. of individual examined for lymphatic 1. No. of people 5-65 y/o who ingested
filariasis - Total 0 MDA drugs - Total
2. No. of individual examined found positive for 2. No. of patients seen - Total
lymphatic filariasis - Total 0 3. No. of suspected cases seen
3. No. of lymphatic filariasis cases examined with 4. No. acute clinically diagnosed cases -
manifestation of either lymphedema,hydrocele, Total
elephantiasis - Total
0 5. No. of confirmed acute cases - Total
6. No. of chronic clinically diagnosed
cases - Total
Section F. _________________________
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
 ___JANUARY_____ YEAR: ____2020___

M1
AGPAKO__________________________
_________________________
_________________________

BRGY
________________________
________________________
r submission to RHU/MHC

Services and Deworming for Women of Reproductive Age

Total A3. Deworming Services SES Total

Col. 3) (Col. 1) (Col. 2) (Col. 3)

NHTS Non-NHTS
1. No. of women 20-49 years old given 2 doses of
15 deworming drugs - Total
0 0 0
15
0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
on B. Maternal Care and Services
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

a. Number of pregnant women seen in the

first trimester who have normal BMI -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of pregnant women seen in the first
trimester who have low BMI - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

7. No. of pregnant women given iodine

capsules – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
8. No. of pregnant women given one dose
of deworming tablet - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
9. No. of pregnant women screened for
syphilis - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
10. No. of pregnant women tested positive
for syphilis - Total

0 0 0 0
 • NHTS 0
• Non-NHTS 0
11. No. of pregnant women screened for
Hepatitis B - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
18. No. of deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
19. No. of live births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20a. No. of live births with normal birth
weight - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20b. No. of live births with low birth weight
- Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
20c. No. of live births with unknown birth
weight- Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
21. No. of deliveries attended by skilled
health professionals - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col 3)  (Col. 4)
rks Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

24a. No. of deliveries in public health

facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
24b. No. of deliveries in private health
facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
25. No. of non-facility-based deliveries -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
26a. No. of vaginal deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
26b. No. of deliveries by cesarean
section – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
27a. No. of full-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
27b. No. of pre-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B3. Postpartum and Newborn Care
28. No. of postpartum women together
with their newborn who completed at
least 2 postpartum check-ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
 29. No. of postpartum women who
completed iron with folic acid
supplementation - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
30. No. of postpartum women with
Vitamin A supplementation – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
ction C. Child Care and Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)

epB 3 - Total 0 0 0 11. PCV 1 - Total 0 0

0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 12. PCV 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 13. PCV 3 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 14. MMR 1 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
0 0 0 15. MMR 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
1 (November) - Total 0 0 0 20. Td, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
e 1 (November) - Total 0 0 0 21. MR, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

34. Children 12-23 mos. who completed

1 mos. old seen - Total
MNP supplementation - Total
0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
 1 mos. given 1 dose of
35. Children 0-59 mos. seen - Total
100,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos seen - Total 0 0 0 36. Stunted - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos. old given 2
37. Wasted - Total
tamin A 200,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
1 months old who completed
38. Overweight/Obese - Total
lementation - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS

2-23 mos. seen - Total 39. Normal - Total

0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col. 1) (Col 2) (Col 3)

y/o dewormed (2 doses) - 43. Adolescents, 10-19 y/o dewormed

0 0 0 (2 doses) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

ren 12-59 mos. old 50. Diarrhea cases 0-59 mos. received
itamin A - Total 0 0 0 ORS w/ zinc - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old seen 51. Pneumonia cases 0-59 mos. old
0 0 0 seen - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old 52. Pneumonia cases 0-59 mos. old
ORS - Total 0 0 0 completed treatment - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
 To be submitted Quarterly
ous Disease Prevention and Control Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
miasis Prevention and Control E2. Schistosomiasis Prevention and Control (Con't.)
le 5-65 y/o who ingested 7. No. confirmed chronic cases - Total
- Total 0
nts seen - Total 0 8. No. of confirmed cases (acute and
ected cases seen 0 chronic) - Total
clinically diagnosed cases - 9. No. of cases treated - Total
0
rmed acute cases - Total 0 10. No. of confirmed chronic cases
nic clinically diagnosed referred to a hospital facility - Total
al 0
_________________________________________
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
M1
RGY
Total

(Col. 3)

New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
 0 0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0 0
0
0
0 0
0
0
0 0
0
0
 0 0
0
0

Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
 Total
(Col 4)

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Total
(Col 4)
0
0
0
0
0
0

0
0
0
 0
0
0
0
0
0

0
0
0

0
0
0

0
0
0
Total
(Col 4)

0
0
0

0
0
0

0
0
0

0
0
0
 Total
(Col 4)
't.)

Total
(Col 4)
 FHSIS REPORT for the MONTH: ___JANUARY_____
Name of Barangay: _____TAGPAKO_________
Name of BHS: _______________________
Name of Municipality/City: _______________________
Name of Province: ________________________
Projected Population of the Year: _______________________
For submission to RHU/MHC

Section A. Family Planning Services and Dewor

A1. Modern FP Unmet Need Age Total

(Col. 1) (Col. 2) (Col. 3)

10-14 15-19 20-49
1. No. of WRA with unmet
need for modern FP - Total 5 5 5
15
• NHTS 5 5 5 15
• Non-NHTS 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
a. Female Sterilization/ BTL - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
b. Male Sterilization/ NSV-Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
c. Condom - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d. Pills - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
 d.1 Pills-POP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d.2 Pills-COC - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
e. Injectables (DMPA/ POI) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
f. Implant - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g. IUD (IUD-I and IUD-PP) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.1 IUD-I- Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.2 IUD-PP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
h. NFP-LAM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
i. NFP-BBT - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
j. NFP-CMM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
k. NFP-STM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
l. NFP-SDM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
m. Total Current Users 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
Section B. Maternal Care
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
1. No. of pregnant women w/
at least 4 prenatal check-
ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
2. No. of pregnant women
assessed of their nutritional
status during the 1st tri. -Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
c. No. of pregnant women
seen in the first trimester
who have high BMI - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
3. No. of pregnant women for
the first time given 2 doses of
Td vaccination - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
4. No. of pregnant women for
the 2nd or more times given
at least 3 doses of Td
vaccination (Td2 Plus) - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
5. No. of pregnant women who
completed the dose of iron
with folic acid
supplementation - Total 0 0 0 0
 • NHTS 0
• Non-NHTS 0
6. No. of pregnant women who
completed doses of calcium
carbonate supplementation -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
12. No. of pregnant women
tested positive for Hepatitis
B - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
13. No. of pregnant women
screened for HIV - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
14. No. of pregnant women
tested for CBC or Hgb&Hct
count - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
15. No. of pregnant women
tested for CBC or Hgb&Hct
count diagnosed with
anemia - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
16. No. of pregnant women
screened for gestational
diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
17.   No. of pregnant women
tested positive for
gestational diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col 3)  (Col. 4)
 Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
a. No. of deliveries attended
by a doctor - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by a nurse – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
c. No. of deliveries attended
by midwives - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
22. No. of deliveries attended by
non-skilled health
professionals - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
a. No. of deliveries attended
by Hilot/TBA - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by others - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
23. No. of health facility-based
deliveries - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
27c. No. of fetal deaths - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
27d. No. of abortion/
miscarriage - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0

Section C. Child Care a

Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
C1. Immunization Services
1. CPAB - Total 0 0 0 6. DPT-HiB-HepB 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
2. BCG - Total 0 0 0 7. OPV 1 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
3. HepB, within 24 hours. - Total 0 0 0 8. OPV 2 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
4. DPT-HiB-HepB 1 - Total 0 0 0 9. OPV 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
5. DPT-HiB-HepB 2 - Total 0 0 0 10. IPV - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
16. FIC - Total 0 0 0 18. Td, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
17. CIC - Total 0 0 0 19. MR, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
C2. Nutrition Services
22. Newborns initiated on breastfeeding
immediately after birth lasting to 90 mins - 28. Infants 6-11 mos. old seen - Total
Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
23. Preterm/LBW infants given iron 29. Infants 6-11 mos. given 1 dose of
supplementation - Total 0 0 0 Vitamin A 100,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
24. Infants 6 mos. old seen - Total 0 0 0 30. Children 12-59 mos seen - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
25. Infants exclusively breastfed until 6th month - 31. Children 12-59 mos. old given 2
Total 0 0 0 doses of Vitamin A 200,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
26. Infants 6 mos. old initiated to complementary 32. Infant 6-11 months old who completed
feeding with continued breastfeeding - Total 0 0 0 MNP supplementation - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
27. Infants 6 mos. old initiated to complementary
feeding but no longer or never been breastfed 33. Children 12-23 mos. seen - Total
- Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
0
40. 1-19 y/o given 2 doses of deworming drug - 42. SAC, 5-9 y/o dewormed (2 doses) -
Total 0 0 0 Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
41. PSAC, 1-4 y/o dewormed (2 doses) - Total 0 0 0
• NHTS 0
• Non-NHTS 0
0
44. Sick Infants 6-11 mos. old seen - Total 47. Sick Children 12-59 mos. old
0 0 0 received Vitamin A - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
45. Sick Infants 6-11 mos. old received 48. Diarrhea cases 0-59 months old seen
Vitamin A - Total 0 0 0 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
49. Diarrhea cases 0-59 months old
46. Sick Children 12-59 mos. old seen - Total
0 0 0 received ORS - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
 To be submitted Qua
Section E. Infectious Disease Preven
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
E1. Filariasis Prevention and Control E2. Schistosomiasis Prevention and Contro
1. No. of individual examined for lymphatic 1. No. of people 5-65 y/o who ingested
filariasis - Total 0 MDA drugs - Total
2. No. of individual examined found positive for 2. No. of patients seen - Total
lymphatic filariasis - Total 0 3. No. of suspected cases seen
3. No. of lymphatic filariasis cases examined with 4. No. acute clinically diagnosed cases -
manifestation of either lymphedema,hydrocele, Total
elephantiasis - Total
0 5. No. of confirmed acute cases - Total
6. No. of chronic clinically diagnosed
cases - Total
Section F. _________________________
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
 ___JANUARY_____ YEAR: ____2020___

M1
AGPAKO__________________________
_________________________
_________________________

BRGY
________________________
________________________
r submission to RHU/MHC

Services and Deworming for Women of Reproductive Age

Total A3. Deworming Services SES Total

Col. 3) (Col. 1) (Col. 2) (Col. 3)

NHTS Non-NHTS
1. No. of women 20-49 years old given 2 doses of
15 deworming drugs - Total
0 0 0
15
0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
on B. Maternal Care and Services
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

a. Number of pregnant women seen in the

first trimester who have normal BMI -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of pregnant women seen in the first
trimester who have low BMI - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

7. No. of pregnant women given iodine

capsules – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
8. No. of pregnant women given one dose
of deworming tablet - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
9. No. of pregnant women screened for
syphilis - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
10. No. of pregnant women tested positive
for syphilis - Total

0 0 0 0
 • NHTS 0
• Non-NHTS 0
11. No. of pregnant women screened for
Hepatitis B - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
18. No. of deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
19. No. of live births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20a. No. of live births with normal birth
weight - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20b. No. of live births with low birth weight
- Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
20c. No. of live births with unknown birth
weight- Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
21. No. of deliveries attended by skilled
health professionals - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col 3)  (Col. 4)
rks Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

24a. No. of deliveries in public health

facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
24b. No. of deliveries in private health
facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
25. No. of non-facility-based deliveries -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
26a. No. of vaginal deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
26b. No. of deliveries by cesarean
section – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
27a. No. of full-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
27b. No. of pre-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B3. Postpartum and Newborn Care
28. No. of postpartum women together
with their newborn who completed at
least 2 postpartum check-ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
 29. No. of postpartum women who
completed iron with folic acid
supplementation - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
30. No. of postpartum women with
Vitamin A supplementation – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
ction C. Child Care and Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)

epB 3 - Total 0 0 0 11. PCV 1 - Total 0 0

0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 12. PCV 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 13. PCV 3 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 14. MMR 1 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
0 0 0 15. MMR 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
1 (November) - Total 0 0 0 20. Td, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
e 1 (November) - Total 0 0 0 21. MR, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

34. Children 12-23 mos. who completed

1 mos. old seen - Total
MNP supplementation - Total
0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
 1 mos. given 1 dose of
35. Children 0-59 mos. seen - Total
100,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos seen - Total 0 0 0 36. Stunted - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos. old given 2
37. Wasted - Total
tamin A 200,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
1 months old who completed
38. Overweight/Obese - Total
lementation - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS

2-23 mos. seen - Total 39. Normal - Total

0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col. 1) (Col 2) (Col 3)

y/o dewormed (2 doses) - 43. Adolescents, 10-19 y/o dewormed

0 0 0 (2 doses) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

ren 12-59 mos. old 50. Diarrhea cases 0-59 mos. received
itamin A - Total 0 0 0 ORS w/ zinc - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old seen 51. Pneumonia cases 0-59 mos. old
0 0 0 seen - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old 52. Pneumonia cases 0-59 mos. old
ORS - Total 0 0 0 completed treatment - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
 To be submitted Quarterly
ous Disease Prevention and Control Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
miasis Prevention and Control E2. Schistosomiasis Prevention and Control (Con't.)
le 5-65 y/o who ingested 7. No. confirmed chronic cases - Total
- Total 0
nts seen - Total 0 8. No. of confirmed cases (acute and
ected cases seen 0 chronic) - Total
clinically diagnosed cases - 9. No. of cases treated - Total
0
rmed acute cases - Total 0 10. No. of confirmed chronic cases
nic clinically diagnosed referred to a hospital facility - Total
al 0
_________________________________________
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
M1
RGY
Total

(Col. 3)

New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
 0 0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0 0
0
0
0 0
0
0
0 0
0
0
 0 0
0
0

Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
 Total
(Col 4)

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Total
(Col 4)
0
0
0
0
0
0

0
0
0
 0
0
0
0
0
0

0
0
0

0
0
0

0
0
0
Total
(Col 4)

0
0
0

0
0
0

0
0
0

0
0
0
 Total
(Col 4)
't.)

Total
(Col 4)
 FHSIS REPORT for the MONTH: ___JANUARY_____
Name of Barangay: _____TAGPAKO_________
Name of BHS: _______________________
Name of Municipality/City: _______________________
Name of Province: ________________________
Projected Population of the Year: _______________________
For submission to RHU/MHC

Section A. Family Planning Services and Dewor

A1. Modern FP Unmet Need Age Total

(Col. 1) (Col. 2) (Col. 3)

10-14 15-19 20-49
1. No. of WRA with unmet
need for modern FP - Total 5 5 5
15
• NHTS 5 5 5 15
• Non-NHTS 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
a. Female Sterilization/ BTL - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
b. Male Sterilization/ NSV-Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
c. Condom - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d. Pills - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
 d.1 Pills-POP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d.2 Pills-COC - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
e. Injectables (DMPA/ POI) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
f. Implant - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g. IUD (IUD-I and IUD-PP) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.1 IUD-I- Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.2 IUD-PP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
h. NFP-LAM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
i. NFP-BBT - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
j. NFP-CMM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
k. NFP-STM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
l. NFP-SDM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
m. Total Current Users 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
Section B. Maternal Care
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
1. No. of pregnant women w/
at least 4 prenatal check-
ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
2. No. of pregnant women
assessed of their nutritional
status during the 1st tri. -Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
c. No. of pregnant women
seen in the first trimester
who have high BMI - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
3. No. of pregnant women for
the first time given 2 doses of
Td vaccination - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
4. No. of pregnant women for
the 2nd or more times given
at least 3 doses of Td
vaccination (Td2 Plus) - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
5. No. of pregnant women who
completed the dose of iron
with folic acid
supplementation - Total 0 0 0 0
 • NHTS 0
• Non-NHTS 0
6. No. of pregnant women who
completed doses of calcium
carbonate supplementation -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
12. No. of pregnant women
tested positive for Hepatitis
B - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
13. No. of pregnant women
screened for HIV - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
14. No. of pregnant women
tested for CBC or Hgb&Hct
count - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
15. No. of pregnant women
tested for CBC or Hgb&Hct
count diagnosed with
anemia - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
16. No. of pregnant women
screened for gestational
diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
17.   No. of pregnant women
tested positive for
gestational diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col 3)  (Col. 4)
 Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
a. No. of deliveries attended
by a doctor - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by a nurse – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
c. No. of deliveries attended
by midwives - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
22. No. of deliveries attended by
non-skilled health
professionals - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
a. No. of deliveries attended
by Hilot/TBA - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by others - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
23. No. of health facility-based
deliveries - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
27c. No. of fetal deaths - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
27d. No. of abortion/
miscarriage - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0

Section C. Child Care a

Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
C1. Immunization Services
1. CPAB - Total 0 0 0 6. DPT-HiB-HepB 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
2. BCG - Total 0 0 0 7. OPV 1 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
3. HepB, within 24 hours. - Total 0 0 0 8. OPV 2 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
4. DPT-HiB-HepB 1 - Total 0 0 0 9. OPV 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
5. DPT-HiB-HepB 2 - Total 0 0 0 10. IPV - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
16. FIC - Total 0 0 0 18. Td, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
17. CIC - Total 0 0 0 19. MR, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
C2. Nutrition Services
22. Newborns initiated on breastfeeding
immediately after birth lasting to 90 mins - 28. Infants 6-11 mos. old seen - Total
Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
23. Preterm/LBW infants given iron 29. Infants 6-11 mos. given 1 dose of
supplementation - Total 0 0 0 Vitamin A 100,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
24. Infants 6 mos. old seen - Total 0 0 0 30. Children 12-59 mos seen - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
25. Infants exclusively breastfed until 6th month - 31. Children 12-59 mos. old given 2
Total 0 0 0 doses of Vitamin A 200,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
26. Infants 6 mos. old initiated to complementary 32. Infant 6-11 months old who completed
feeding with continued breastfeeding - Total 0 0 0 MNP supplementation - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
27. Infants 6 mos. old initiated to complementary
feeding but no longer or never been breastfed 33. Children 12-23 mos. seen - Total
- Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
0
40. 1-19 y/o given 2 doses of deworming drug - 42. SAC, 5-9 y/o dewormed (2 doses) -
Total 0 0 0 Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
41. PSAC, 1-4 y/o dewormed (2 doses) - Total 0 0 0
• NHTS 0
• Non-NHTS 0
0
44. Sick Infants 6-11 mos. old seen - Total 47. Sick Children 12-59 mos. old
0 0 0 received Vitamin A - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
45. Sick Infants 6-11 mos. old received 48. Diarrhea cases 0-59 months old seen
Vitamin A - Total 0 0 0 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
49. Diarrhea cases 0-59 months old
46. Sick Children 12-59 mos. old seen - Total
0 0 0 received ORS - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
 To be submitted Qua
Section E. Infectious Disease Preven
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
E1. Filariasis Prevention and Control E2. Schistosomiasis Prevention and Contro
1. No. of individual examined for lymphatic 1. No. of people 5-65 y/o who ingested
filariasis - Total 0 MDA drugs - Total
2. No. of individual examined found positive for 2. No. of patients seen - Total
lymphatic filariasis - Total 0 3. No. of suspected cases seen
3. No. of lymphatic filariasis cases examined with 4. No. acute clinically diagnosed cases -
manifestation of either lymphedema,hydrocele, Total
elephantiasis - Total
0 5. No. of confirmed acute cases - Total
6. No. of chronic clinically diagnosed
cases - Total
Section F. _________________________
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
 ___JANUARY_____ YEAR: ____2020___

M1
AGPAKO__________________________
_________________________
_________________________

BRGY
________________________
________________________
r submission to RHU/MHC

Services and Deworming for Women of Reproductive Age

Total A3. Deworming Services SES Total

Col. 3) (Col. 1) (Col. 2) (Col. 3)

NHTS Non-NHTS
1. No. of women 20-49 years old given 2 doses of
15 deworming drugs - Total
0 0 0
15
0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
on B. Maternal Care and Services
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

a. Number of pregnant women seen in the

first trimester who have normal BMI -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of pregnant women seen in the first
trimester who have low BMI - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

7. No. of pregnant women given iodine

capsules – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
8. No. of pregnant women given one dose
of deworming tablet - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
9. No. of pregnant women screened for
syphilis - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
10. No. of pregnant women tested positive
for syphilis - Total

0 0 0 0
 • NHTS 0
• Non-NHTS 0
11. No. of pregnant women screened for
Hepatitis B - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
18. No. of deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
19. No. of live births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20a. No. of live births with normal birth
weight - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20b. No. of live births with low birth weight
- Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
20c. No. of live births with unknown birth
weight- Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
21. No. of deliveries attended by skilled
health professionals - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col 3)  (Col. 4)
rks Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

24a. No. of deliveries in public health

facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
24b. No. of deliveries in private health
facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
25. No. of non-facility-based deliveries -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
26a. No. of vaginal deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
26b. No. of deliveries by cesarean
section – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
27a. No. of full-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
27b. No. of pre-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B3. Postpartum and Newborn Care
28. No. of postpartum women together
with their newborn who completed at
least 2 postpartum check-ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
 29. No. of postpartum women who
completed iron with folic acid
supplementation - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
30. No. of postpartum women with
Vitamin A supplementation – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
ction C. Child Care and Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)

epB 3 - Total 0 0 0 11. PCV 1 - Total 0 0

0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 12. PCV 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 13. PCV 3 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 14. MMR 1 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
0 0 0 15. MMR 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
1 (November) - Total 0 0 0 20. Td, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
e 1 (November) - Total 0 0 0 21. MR, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

34. Children 12-23 mos. who completed

1 mos. old seen - Total
MNP supplementation - Total
0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
 1 mos. given 1 dose of
35. Children 0-59 mos. seen - Total
100,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos seen - Total 0 0 0 36. Stunted - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos. old given 2
37. Wasted - Total
tamin A 200,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
1 months old who completed
38. Overweight/Obese - Total
lementation - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS

2-23 mos. seen - Total 39. Normal - Total

0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col. 1) (Col 2) (Col 3)

y/o dewormed (2 doses) - 43. Adolescents, 10-19 y/o dewormed

0 0 0 (2 doses) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

ren 12-59 mos. old 50. Diarrhea cases 0-59 mos. received
itamin A - Total 0 0 0 ORS w/ zinc - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old seen 51. Pneumonia cases 0-59 mos. old
0 0 0 seen - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old 52. Pneumonia cases 0-59 mos. old
ORS - Total 0 0 0 completed treatment - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
 To be submitted Quarterly
ous Disease Prevention and Control Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
miasis Prevention and Control E2. Schistosomiasis Prevention and Control (Con't.)
le 5-65 y/o who ingested 7. No. confirmed chronic cases - Total
- Total 0
nts seen - Total 0 8. No. of confirmed cases (acute and
ected cases seen 0 chronic) - Total
clinically diagnosed cases - 9. No. of cases treated - Total
0
rmed acute cases - Total 0 10. No. of confirmed chronic cases
nic clinically diagnosed referred to a hospital facility - Total
al 0
_________________________________________
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
M1
RGY
Total

(Col. 3)

New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
 0 0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0 0
0
0
0 0
0
0
0 0
0
0
 0 0
0
0

Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
 Total
(Col 4)

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Total
(Col 4)
0
0
0
0
0
0

0
0
0
 0
0
0
0
0
0

0
0
0

0
0
0

0
0
0
Total
(Col 4)

0
0
0

0
0
0

0
0
0

0
0
0
 Total
(Col 4)
't.)

Total
(Col 4)
 FHSIS REPORT for the MONTH: ___JANUARY_____
Name of Barangay: _____TAGPAKO_________
Name of BHS: _______________________
Name of Municipality/City: _______________________
Name of Province: ________________________
Projected Population of the Year: _______________________
For submission to RHU/MHC

Section A. Family Planning Services and Dewor

A1. Modern FP Unmet Need Age Total

(Col. 1) (Col. 2) (Col. 3)

10-14 15-19 20-49
1. No. of WRA with unmet
need for modern FP - Total 5 5 5
15
• NHTS 5 5 5 15
• Non-NHTS 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
a. Female Sterilization/ BTL - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
b. Male Sterilization/ NSV-Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
c. Condom - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d. Pills - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
 d.1 Pills-POP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d.2 Pills-COC - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
e. Injectables (DMPA/ POI) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
f. Implant - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g. IUD (IUD-I and IUD-PP) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.1 IUD-I- Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.2 IUD-PP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
h. NFP-LAM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
i. NFP-BBT - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
j. NFP-CMM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
k. NFP-STM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
l. NFP-SDM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
m. Total Current Users 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
Section B. Maternal Care
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
1. No. of pregnant women w/
at least 4 prenatal check-
ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
2. No. of pregnant women
assessed of their nutritional
status during the 1st tri. -Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
c. No. of pregnant women
seen in the first trimester
who have high BMI - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
3. No. of pregnant women for
the first time given 2 doses of
Td vaccination - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
4. No. of pregnant women for
the 2nd or more times given
at least 3 doses of Td
vaccination (Td2 Plus) - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
5. No. of pregnant women who
completed the dose of iron
with folic acid
supplementation - Total 0 0 0 0
 • NHTS 0
• Non-NHTS 0
6. No. of pregnant women who
completed doses of calcium
carbonate supplementation -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
12. No. of pregnant women
tested positive for Hepatitis
B - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
13. No. of pregnant women
screened for HIV - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
14. No. of pregnant women
tested for CBC or Hgb&Hct
count - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
15. No. of pregnant women
tested for CBC or Hgb&Hct
count diagnosed with
anemia - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
16. No. of pregnant women
screened for gestational
diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
17.   No. of pregnant women
tested positive for
gestational diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col 3)  (Col. 4)
 Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
a. No. of deliveries attended
by a doctor - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by a nurse – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
c. No. of deliveries attended
by midwives - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
22. No. of deliveries attended by
non-skilled health
professionals - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
a. No. of deliveries attended
by Hilot/TBA - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by others - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
23. No. of health facility-based
deliveries - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
27c. No. of fetal deaths - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
27d. No. of abortion/
miscarriage - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0

Section C. Child Care a

Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
C1. Immunization Services
1. CPAB - Total 0 0 0 6. DPT-HiB-HepB 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
2. BCG - Total 0 0 0 7. OPV 1 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
3. HepB, within 24 hours. - Total 0 0 0 8. OPV 2 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
4. DPT-HiB-HepB 1 - Total 0 0 0 9. OPV 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
5. DPT-HiB-HepB 2 - Total 0 0 0 10. IPV - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
16. FIC - Total 0 0 0 18. Td, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
17. CIC - Total 0 0 0 19. MR, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
C2. Nutrition Services
22. Newborns initiated on breastfeeding
immediately after birth lasting to 90 mins - 28. Infants 6-11 mos. old seen - Total
Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
23. Preterm/LBW infants given iron 29. Infants 6-11 mos. given 1 dose of
supplementation - Total 0 0 0 Vitamin A 100,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
24. Infants 6 mos. old seen - Total 0 0 0 30. Children 12-59 mos seen - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
25. Infants exclusively breastfed until 6th month - 31. Children 12-59 mos. old given 2
Total 0 0 0 doses of Vitamin A 200,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
26. Infants 6 mos. old initiated to complementary 32. Infant 6-11 months old who completed
feeding with continued breastfeeding - Total 0 0 0 MNP supplementation - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
27. Infants 6 mos. old initiated to complementary
feeding but no longer or never been breastfed 33. Children 12-23 mos. seen - Total
- Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
0
40. 1-19 y/o given 2 doses of deworming drug - 42. SAC, 5-9 y/o dewormed (2 doses) -
Total 0 0 0 Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
41. PSAC, 1-4 y/o dewormed (2 doses) - Total 0 0 0
• NHTS 0
• Non-NHTS 0
0
44. Sick Infants 6-11 mos. old seen - Total 47. Sick Children 12-59 mos. old
0 0 0 received Vitamin A - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
45. Sick Infants 6-11 mos. old received 48. Diarrhea cases 0-59 months old seen
Vitamin A - Total 0 0 0 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
49. Diarrhea cases 0-59 months old
46. Sick Children 12-59 mos. old seen - Total
0 0 0 received ORS - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
 To be submitted Qua
Section E. Infectious Disease Preven
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
E1. Filariasis Prevention and Control E2. Schistosomiasis Prevention and Contro
1. No. of individual examined for lymphatic 1. No. of people 5-65 y/o who ingested
filariasis - Total 0 MDA drugs - Total
2. No. of individual examined found positive for 2. No. of patients seen - Total
lymphatic filariasis - Total 0 3. No. of suspected cases seen
3. No. of lymphatic filariasis cases examined with 4. No. acute clinically diagnosed cases -
manifestation of either lymphedema,hydrocele, Total
elephantiasis - Total
0 5. No. of confirmed acute cases - Total
6. No. of chronic clinically diagnosed
cases - Total
Section F. _________________________
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
 ___JANUARY_____ YEAR: ____2020___

M1
AGPAKO__________________________
_________________________
_________________________

BRGY
________________________
________________________
r submission to RHU/MHC

Services and Deworming for Women of Reproductive Age

Total A3. Deworming Services SES Total

Col. 3) (Col. 1) (Col. 2) (Col. 3)

NHTS Non-NHTS
1. No. of women 20-49 years old given 2 doses of
15 deworming drugs - Total
0 0 0
15
0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
on B. Maternal Care and Services
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

a. Number of pregnant women seen in the

first trimester who have normal BMI -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of pregnant women seen in the first
trimester who have low BMI - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

7. No. of pregnant women given iodine

capsules – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
8. No. of pregnant women given one dose
of deworming tablet - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
9. No. of pregnant women screened for
syphilis - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
10. No. of pregnant women tested positive
for syphilis - Total

0 0 0 0
 • NHTS 0
• Non-NHTS 0
11. No. of pregnant women screened for
Hepatitis B - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
18. No. of deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
19. No. of live births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20a. No. of live births with normal birth
weight - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20b. No. of live births with low birth weight
- Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
20c. No. of live births with unknown birth
weight- Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
21. No. of deliveries attended by skilled
health professionals - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col 3)  (Col. 4)
rks Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

24a. No. of deliveries in public health

facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
24b. No. of deliveries in private health
facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
25. No. of non-facility-based deliveries -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
26a. No. of vaginal deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
26b. No. of deliveries by cesarean
section – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
27a. No. of full-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
27b. No. of pre-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B3. Postpartum and Newborn Care
28. No. of postpartum women together
with their newborn who completed at
least 2 postpartum check-ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
 29. No. of postpartum women who
completed iron with folic acid
supplementation - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
30. No. of postpartum women with
Vitamin A supplementation – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
ction C. Child Care and Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)

epB 3 - Total 0 0 0 11. PCV 1 - Total 0 0

0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 12. PCV 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 13. PCV 3 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 14. MMR 1 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
0 0 0 15. MMR 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
1 (November) - Total 0 0 0 20. Td, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
e 1 (November) - Total 0 0 0 21. MR, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

34. Children 12-23 mos. who completed

1 mos. old seen - Total
MNP supplementation - Total
0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
 1 mos. given 1 dose of
35. Children 0-59 mos. seen - Total
100,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos seen - Total 0 0 0 36. Stunted - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos. old given 2
37. Wasted - Total
tamin A 200,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
1 months old who completed
38. Overweight/Obese - Total
lementation - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS

2-23 mos. seen - Total 39. Normal - Total

0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col. 1) (Col 2) (Col 3)

y/o dewormed (2 doses) - 43. Adolescents, 10-19 y/o dewormed

0 0 0 (2 doses) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

ren 12-59 mos. old 50. Diarrhea cases 0-59 mos. received
itamin A - Total 0 0 0 ORS w/ zinc - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old seen 51. Pneumonia cases 0-59 mos. old
0 0 0 seen - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old 52. Pneumonia cases 0-59 mos. old
ORS - Total 0 0 0 completed treatment - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
 To be submitted Quarterly
ous Disease Prevention and Control Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
miasis Prevention and Control E2. Schistosomiasis Prevention and Control (Con't.)
le 5-65 y/o who ingested 7. No. confirmed chronic cases - Total
- Total 0
nts seen - Total 0 8. No. of confirmed cases (acute and
ected cases seen 0 chronic) - Total
clinically diagnosed cases - 9. No. of cases treated - Total
0
rmed acute cases - Total 0 10. No. of confirmed chronic cases
nic clinically diagnosed referred to a hospital facility - Total
al 0
_________________________________________
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
M1
RGY
Total

(Col. 3)

New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
 0 0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0 0
0
0
0 0
0
0
0 0
0
0
 0 0
0
0

Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
 Total
(Col 4)

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Total
(Col 4)
0
0
0
0
0
0

0
0
0
 0
0
0
0
0
0

0
0
0

0
0
0

0
0
0
Total
(Col 4)

0
0
0

0
0
0

0
0
0

0
0
0
 Total
(Col 4)
't.)

Total
(Col 4)
 FHSIS REPORT for the MONTH: ___JANUARY_____
Name of Barangay: _____TAGPAKO_________
Name of BHS: _______________________
Name of Municipality/City: _______________________
Name of Province: ________________________
Projected Population of the Year: _______________________
For submission to RHU/MHC

Section A. Family Planning Services and Dewor

A1. Modern FP Unmet Need Age Total

(Col. 1) (Col. 2) (Col. 3)

10-14 15-19 20-49
1. No. of WRA with unmet
need for modern FP - Total 5 5 5
15
• NHTS 5 5 5 15
• Non-NHTS 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
a. Female Sterilization/ BTL - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
b. Male Sterilization/ NSV-Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
c. Condom - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d. Pills - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
 d.1 Pills-POP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d.2 Pills-COC - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
e. Injectables (DMPA/ POI) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
f. Implant - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g. IUD (IUD-I and IUD-PP) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.1 IUD-I- Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.2 IUD-PP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
h. NFP-LAM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
i. NFP-BBT - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
j. NFP-CMM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
k. NFP-STM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
l. NFP-SDM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
m. Total Current Users 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
Section B. Maternal Care
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
1. No. of pregnant women w/
at least 4 prenatal check-
ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
2. No. of pregnant women
assessed of their nutritional
status during the 1st tri. -Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
c. No. of pregnant women
seen in the first trimester
who have high BMI - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
3. No. of pregnant women for
the first time given 2 doses of
Td vaccination - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
4. No. of pregnant women for
the 2nd or more times given
at least 3 doses of Td
vaccination (Td2 Plus) - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
5. No. of pregnant women who
completed the dose of iron
with folic acid
supplementation - Total 0 0 0 0
 • NHTS 0
• Non-NHTS 0
6. No. of pregnant women who
completed doses of calcium
carbonate supplementation -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
12. No. of pregnant women
tested positive for Hepatitis
B - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
13. No. of pregnant women
screened for HIV - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
14. No. of pregnant women
tested for CBC or Hgb&Hct
count - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
15. No. of pregnant women
tested for CBC or Hgb&Hct
count diagnosed with
anemia - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
16. No. of pregnant women
screened for gestational
diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
17.   No. of pregnant women
tested positive for
gestational diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col 3)  (Col. 4)
 Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
a. No. of deliveries attended
by a doctor - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by a nurse – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
c. No. of deliveries attended
by midwives - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
22. No. of deliveries attended by
non-skilled health
professionals - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
a. No. of deliveries attended
by Hilot/TBA - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by others - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
23. No. of health facility-based
deliveries - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
27c. No. of fetal deaths - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
27d. No. of abortion/
miscarriage - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0

Section C. Child Care a

Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
C1. Immunization Services
1. CPAB - Total 0 0 0 6. DPT-HiB-HepB 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
2. BCG - Total 0 0 0 7. OPV 1 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
3. HepB, within 24 hours. - Total 0 0 0 8. OPV 2 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
4. DPT-HiB-HepB 1 - Total 0 0 0 9. OPV 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
5. DPT-HiB-HepB 2 - Total 0 0 0 10. IPV - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
16. FIC - Total 0 0 0 18. Td, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
17. CIC - Total 0 0 0 19. MR, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
C2. Nutrition Services
22. Newborns initiated on breastfeeding
immediately after birth lasting to 90 mins - 28. Infants 6-11 mos. old seen - Total
Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
23. Preterm/LBW infants given iron 29. Infants 6-11 mos. given 1 dose of
supplementation - Total 0 0 0 Vitamin A 100,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
24. Infants 6 mos. old seen - Total 0 0 0 30. Children 12-59 mos seen - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
25. Infants exclusively breastfed until 6th month - 31. Children 12-59 mos. old given 2
Total 0 0 0 doses of Vitamin A 200,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
26. Infants 6 mos. old initiated to complementary 32. Infant 6-11 months old who completed
feeding with continued breastfeeding - Total 0 0 0 MNP supplementation - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
27. Infants 6 mos. old initiated to complementary
feeding but no longer or never been breastfed 33. Children 12-23 mos. seen - Total
- Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
0
40. 1-19 y/o given 2 doses of deworming drug - 42. SAC, 5-9 y/o dewormed (2 doses) -
Total 0 0 0 Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
41. PSAC, 1-4 y/o dewormed (2 doses) - Total 0 0 0
• NHTS 0
• Non-NHTS 0
0
44. Sick Infants 6-11 mos. old seen - Total 47. Sick Children 12-59 mos. old
0 0 0 received Vitamin A - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
45. Sick Infants 6-11 mos. old received 48. Diarrhea cases 0-59 months old seen
Vitamin A - Total 0 0 0 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
49. Diarrhea cases 0-59 months old
46. Sick Children 12-59 mos. old seen - Total
0 0 0 received ORS - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
 To be submitted Qua
Section E. Infectious Disease Preven
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
E1. Filariasis Prevention and Control E2. Schistosomiasis Prevention and Contro
1. No. of individual examined for lymphatic 1. No. of people 5-65 y/o who ingested
filariasis - Total 0 MDA drugs - Total
2. No. of individual examined found positive for 2. No. of patients seen - Total
lymphatic filariasis - Total 0 3. No. of suspected cases seen
3. No. of lymphatic filariasis cases examined with 4. No. acute clinically diagnosed cases -
manifestation of either lymphedema,hydrocele, Total
elephantiasis - Total
0 5. No. of confirmed acute cases - Total
6. No. of chronic clinically diagnosed
cases - Total
Section F. _________________________
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
 ___JANUARY_____ YEAR: ____2020___

M1
AGPAKO__________________________
_________________________
_________________________

BRGY
________________________
________________________
r submission to RHU/MHC

Services and Deworming for Women of Reproductive Age

Total A3. Deworming Services SES Total

Col. 3) (Col. 1) (Col. 2) (Col. 3)

NHTS Non-NHTS
1. No. of women 20-49 years old given 2 doses of
15 deworming drugs - Total
0 0 0
15
0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
on B. Maternal Care and Services
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

a. Number of pregnant women seen in the

first trimester who have normal BMI -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of pregnant women seen in the first
trimester who have low BMI - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

7. No. of pregnant women given iodine

capsules – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
8. No. of pregnant women given one dose
of deworming tablet - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
9. No. of pregnant women screened for
syphilis - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
10. No. of pregnant women tested positive
for syphilis - Total

0 0 0 0
 • NHTS 0
• Non-NHTS 0
11. No. of pregnant women screened for
Hepatitis B - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
18. No. of deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
19. No. of live births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20a. No. of live births with normal birth
weight - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20b. No. of live births with low birth weight
- Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
20c. No. of live births with unknown birth
weight- Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
21. No. of deliveries attended by skilled
health professionals - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col 3)  (Col. 4)
rks Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

24a. No. of deliveries in public health

facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
24b. No. of deliveries in private health
facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
25. No. of non-facility-based deliveries -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
26a. No. of vaginal deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
26b. No. of deliveries by cesarean
section – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
27a. No. of full-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
27b. No. of pre-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B3. Postpartum and Newborn Care
28. No. of postpartum women together
with their newborn who completed at
least 2 postpartum check-ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
 29. No. of postpartum women who
completed iron with folic acid
supplementation - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
30. No. of postpartum women with
Vitamin A supplementation – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
ction C. Child Care and Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)

epB 3 - Total 0 0 0 11. PCV 1 - Total 0 0

0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 12. PCV 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 13. PCV 3 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 14. MMR 1 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
0 0 0 15. MMR 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
1 (November) - Total 0 0 0 20. Td, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
e 1 (November) - Total 0 0 0 21. MR, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

34. Children 12-23 mos. who completed

1 mos. old seen - Total
MNP supplementation - Total
0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
 1 mos. given 1 dose of
35. Children 0-59 mos. seen - Total
100,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos seen - Total 0 0 0 36. Stunted - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos. old given 2
37. Wasted - Total
tamin A 200,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
1 months old who completed
38. Overweight/Obese - Total
lementation - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS

2-23 mos. seen - Total 39. Normal - Total

0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col. 1) (Col 2) (Col 3)

y/o dewormed (2 doses) - 43. Adolescents, 10-19 y/o dewormed

0 0 0 (2 doses) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

ren 12-59 mos. old 50. Diarrhea cases 0-59 mos. received
itamin A - Total 0 0 0 ORS w/ zinc - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old seen 51. Pneumonia cases 0-59 mos. old
0 0 0 seen - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old 52. Pneumonia cases 0-59 mos. old
ORS - Total 0 0 0 completed treatment - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
 To be submitted Quarterly
ous Disease Prevention and Control Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
miasis Prevention and Control E2. Schistosomiasis Prevention and Control (Con't.)
le 5-65 y/o who ingested 7. No. confirmed chronic cases - Total
- Total 0
nts seen - Total 0 8. No. of confirmed cases (acute and
ected cases seen 0 chronic) - Total
clinically diagnosed cases - 9. No. of cases treated - Total
0
rmed acute cases - Total 0 10. No. of confirmed chronic cases
nic clinically diagnosed referred to a hospital facility - Total
al 0
_________________________________________
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
M1
RGY
Total

(Col. 3)

New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
 0 0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0 0
0
0
0 0
0
0
0 0
0
0
 0 0
0
0

Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
 Total
(Col 4)

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Total
(Col 4)
0
0
0
0
0
0

0
0
0
 0
0
0
0
0
0

0
0
0

0
0
0

0
0
0
Total
(Col 4)

0
0
0

0
0
0

0
0
0

0
0
0
 Total
(Col 4)
't.)

Total
(Col 4)
 FHSIS REPORT for the MONTH: ___JANUARY_____
Name of Barangay: _____TAGPAKO_________
Name of BHS: _______________________
Name of Municipality/City: _______________________
Name of Province: ________________________
Projected Population of the Year: _______________________
For submission to RHU/MHC

Section A. Family Planning Services and Dewor

A1. Modern FP Unmet Need Age Total

(Col. 1) (Col. 2) (Col. 3)

10-14 15-19 20-49
1. No. of WRA with unmet
need for modern FP - Total 5 5 5
15
• NHTS 5 5 5 15
• Non-NHTS 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
a. Female Sterilization/ BTL - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
b. Male Sterilization/ NSV-Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
c. Condom - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d. Pills - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
 d.1 Pills-POP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d.2 Pills-COC - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
e. Injectables (DMPA/ POI) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
f. Implant - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g. IUD (IUD-I and IUD-PP) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.1 IUD-I- Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.2 IUD-PP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
h. NFP-LAM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
i. NFP-BBT - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
j. NFP-CMM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
k. NFP-STM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
l. NFP-SDM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
m. Total Current Users 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
Section B. Maternal Care
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
1. No. of pregnant women w/
at least 4 prenatal check-
ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
2. No. of pregnant women
assessed of their nutritional
status during the 1st tri. -Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
c. No. of pregnant women
seen in the first trimester
who have high BMI - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
3. No. of pregnant women for
the first time given 2 doses of
Td vaccination - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
4. No. of pregnant women for
the 2nd or more times given
at least 3 doses of Td
vaccination (Td2 Plus) - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
5. No. of pregnant women who
completed the dose of iron
with folic acid
supplementation - Total 0 0 0 0
 • NHTS 0
• Non-NHTS 0
6. No. of pregnant women who
completed doses of calcium
carbonate supplementation -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
12. No. of pregnant women
tested positive for Hepatitis
B - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
13. No. of pregnant women
screened for HIV - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
14. No. of pregnant women
tested for CBC or Hgb&Hct
count - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
15. No. of pregnant women
tested for CBC or Hgb&Hct
count diagnosed with
anemia - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
16. No. of pregnant women
screened for gestational
diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
17.   No. of pregnant women
tested positive for
gestational diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col 3)  (Col. 4)
 Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
a. No. of deliveries attended
by a doctor - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by a nurse – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
c. No. of deliveries attended
by midwives - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
22. No. of deliveries attended by
non-skilled health
professionals - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
a. No. of deliveries attended
by Hilot/TBA - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by others - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
23. No. of health facility-based
deliveries - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
27c. No. of fetal deaths - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
27d. No. of abortion/
miscarriage - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0

Section C. Child Care a

Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
C1. Immunization Services
1. CPAB - Total 0 0 0 6. DPT-HiB-HepB 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
2. BCG - Total 0 0 0 7. OPV 1 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
3. HepB, within 24 hours. - Total 0 0 0 8. OPV 2 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
4. DPT-HiB-HepB 1 - Total 0 0 0 9. OPV 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
5. DPT-HiB-HepB 2 - Total 0 0 0 10. IPV - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
16. FIC - Total 0 0 0 18. Td, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
17. CIC - Total 0 0 0 19. MR, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
C2. Nutrition Services
22. Newborns initiated on breastfeeding
immediately after birth lasting to 90 mins - 28. Infants 6-11 mos. old seen - Total
Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
23. Preterm/LBW infants given iron 29. Infants 6-11 mos. given 1 dose of
supplementation - Total 0 0 0 Vitamin A 100,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
24. Infants 6 mos. old seen - Total 0 0 0 30. Children 12-59 mos seen - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
25. Infants exclusively breastfed until 6th month - 31. Children 12-59 mos. old given 2
Total 0 0 0 doses of Vitamin A 200,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
26. Infants 6 mos. old initiated to complementary 32. Infant 6-11 months old who completed
feeding with continued breastfeeding - Total 0 0 0 MNP supplementation - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
27. Infants 6 mos. old initiated to complementary
feeding but no longer or never been breastfed 33. Children 12-23 mos. seen - Total
- Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
0
40. 1-19 y/o given 2 doses of deworming drug - 42. SAC, 5-9 y/o dewormed (2 doses) -
Total 0 0 0 Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
41. PSAC, 1-4 y/o dewormed (2 doses) - Total 0 0 0
• NHTS 0
• Non-NHTS 0
0
44. Sick Infants 6-11 mos. old seen - Total 47. Sick Children 12-59 mos. old
0 0 0 received Vitamin A - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
45. Sick Infants 6-11 mos. old received 48. Diarrhea cases 0-59 months old seen
Vitamin A - Total 0 0 0 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
49. Diarrhea cases 0-59 months old
46. Sick Children 12-59 mos. old seen - Total
0 0 0 received ORS - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
 To be submitted Qua
Section E. Infectious Disease Preven
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
E1. Filariasis Prevention and Control E2. Schistosomiasis Prevention and Contro
1. No. of individual examined for lymphatic 1. No. of people 5-65 y/o who ingested
filariasis - Total 0 MDA drugs - Total
2. No. of individual examined found positive for 2. No. of patients seen - Total
lymphatic filariasis - Total 0 3. No. of suspected cases seen
3. No. of lymphatic filariasis cases examined with 4. No. acute clinically diagnosed cases -
manifestation of either lymphedema,hydrocele, Total
elephantiasis - Total
0 5. No. of confirmed acute cases - Total
6. No. of chronic clinically diagnosed
cases - Total
Section F. _________________________
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
 ___JANUARY_____ YEAR: ____2020___

M1
AGPAKO__________________________
_________________________
_________________________

BRGY
________________________
________________________
r submission to RHU/MHC

Services and Deworming for Women of Reproductive Age

Total A3. Deworming Services SES Total

Col. 3) (Col. 1) (Col. 2) (Col. 3)

NHTS Non-NHTS
1. No. of women 20-49 years old given 2 doses of
15 deworming drugs - Total
0 0 0
15
0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
on B. Maternal Care and Services
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

a. Number of pregnant women seen in the

first trimester who have normal BMI -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of pregnant women seen in the first
trimester who have low BMI - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

7. No. of pregnant women given iodine

capsules – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
8. No. of pregnant women given one dose
of deworming tablet - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
9. No. of pregnant women screened for
syphilis - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
10. No. of pregnant women tested positive
for syphilis - Total

0 0 0 0
 • NHTS 0
• Non-NHTS 0
11. No. of pregnant women screened for
Hepatitis B - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
18. No. of deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
19. No. of live births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20a. No. of live births with normal birth
weight - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20b. No. of live births with low birth weight
- Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
20c. No. of live births with unknown birth
weight- Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
21. No. of deliveries attended by skilled
health professionals - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col 3)  (Col. 4)
rks Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

24a. No. of deliveries in public health

facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
24b. No. of deliveries in private health
facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
25. No. of non-facility-based deliveries -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
26a. No. of vaginal deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
26b. No. of deliveries by cesarean
section – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
27a. No. of full-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
27b. No. of pre-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B3. Postpartum and Newborn Care
28. No. of postpartum women together
with their newborn who completed at
least 2 postpartum check-ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
 29. No. of postpartum women who
completed iron with folic acid
supplementation - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
30. No. of postpartum women with
Vitamin A supplementation – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
ction C. Child Care and Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)

epB 3 - Total 0 0 0 11. PCV 1 - Total 0 0

0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 12. PCV 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 13. PCV 3 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 14. MMR 1 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
0 0 0 15. MMR 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
1 (November) - Total 0 0 0 20. Td, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
e 1 (November) - Total 0 0 0 21. MR, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

34. Children 12-23 mos. who completed

1 mos. old seen - Total
MNP supplementation - Total
0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
 1 mos. given 1 dose of
35. Children 0-59 mos. seen - Total
100,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos seen - Total 0 0 0 36. Stunted - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos. old given 2
37. Wasted - Total
tamin A 200,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
1 months old who completed
38. Overweight/Obese - Total
lementation - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS

2-23 mos. seen - Total 39. Normal - Total

0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col. 1) (Col 2) (Col 3)

y/o dewormed (2 doses) - 43. Adolescents, 10-19 y/o dewormed

0 0 0 (2 doses) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

ren 12-59 mos. old 50. Diarrhea cases 0-59 mos. received
itamin A - Total 0 0 0 ORS w/ zinc - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old seen 51. Pneumonia cases 0-59 mos. old
0 0 0 seen - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old 52. Pneumonia cases 0-59 mos. old
ORS - Total 0 0 0 completed treatment - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
 To be submitted Quarterly
ous Disease Prevention and Control Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
miasis Prevention and Control E2. Schistosomiasis Prevention and Control (Con't.)
le 5-65 y/o who ingested 7. No. confirmed chronic cases - Total
- Total 0
nts seen - Total 0 8. No. of confirmed cases (acute and
ected cases seen 0 chronic) - Total
clinically diagnosed cases - 9. No. of cases treated - Total
0
rmed acute cases - Total 0 10. No. of confirmed chronic cases
nic clinically diagnosed referred to a hospital facility - Total
al 0
_________________________________________
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
M1
RGY
Total

(Col. 3)

New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
 0 0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0 0
0
0
0 0
0
0
0 0
0
0
 0 0
0
0

Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
 Total
(Col 4)

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Total
(Col 4)
0
0
0
0
0
0

0
0
0
 0
0
0
0
0
0

0
0
0

0
0
0

0
0
0
Total
(Col 4)

0
0
0

0
0
0

0
0
0

0
0
0
 Total
(Col 4)
't.)

Total
(Col 4)
 FHSIS REPORT for the MONTH: ___JANUARY_____
Name of Barangay: _____TAGPAKO_________
Name of BHS: _______________________
Name of Municipality/City: _______________________
Name of Province: ________________________
Projected Population of the Year: _______________________
For submission to RHU/MHC

Section A. Family Planning Services and Dewor

A1. Modern FP Unmet Need Age Total

(Col. 1) (Col. 2) (Col. 3)

10-14 15-19 20-49
1. No. of WRA with unmet
need for modern FP - Total 5 5 5
15
• NHTS 5 5 5 15
• Non-NHTS 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
a. Female Sterilization/ BTL - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
b. Male Sterilization/ NSV-Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
c. Condom - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d. Pills - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
 d.1 Pills-POP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d.2 Pills-COC - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
e. Injectables (DMPA/ POI) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
f. Implant - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g. IUD (IUD-I and IUD-PP) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.1 IUD-I- Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.2 IUD-PP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
h. NFP-LAM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
i. NFP-BBT - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
j. NFP-CMM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
k. NFP-STM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
l. NFP-SDM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
m. Total Current Users 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
Section B. Maternal Care
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
1. No. of pregnant women w/
at least 4 prenatal check-
ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
2. No. of pregnant women
assessed of their nutritional
status during the 1st tri. -Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
c. No. of pregnant women
seen in the first trimester
who have high BMI - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
3. No. of pregnant women for
the first time given 2 doses of
Td vaccination - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
4. No. of pregnant women for
the 2nd or more times given
at least 3 doses of Td
vaccination (Td2 Plus) - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
5. No. of pregnant women who
completed the dose of iron
with folic acid
supplementation - Total 0 0 0 0
 • NHTS 0
• Non-NHTS 0
6. No. of pregnant women who
completed doses of calcium
carbonate supplementation -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
12. No. of pregnant women
tested positive for Hepatitis
B - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
13. No. of pregnant women
screened for HIV - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
14. No. of pregnant women
tested for CBC or Hgb&Hct
count - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
15. No. of pregnant women
tested for CBC or Hgb&Hct
count diagnosed with
anemia - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
16. No. of pregnant women
screened for gestational
diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
17.   No. of pregnant women
tested positive for
gestational diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col 3)  (Col. 4)
 Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
a. No. of deliveries attended
by a doctor - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by a nurse – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
c. No. of deliveries attended
by midwives - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
22. No. of deliveries attended by
non-skilled health
professionals - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
a. No. of deliveries attended
by Hilot/TBA - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by others - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
23. No. of health facility-based
deliveries - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
27c. No. of fetal deaths - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
27d. No. of abortion/
miscarriage - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0

Section C. Child Care a

Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
C1. Immunization Services
1. CPAB - Total 0 0 0 6. DPT-HiB-HepB 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
2. BCG - Total 0 0 0 7. OPV 1 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
3. HepB, within 24 hours. - Total 0 0 0 8. OPV 2 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
4. DPT-HiB-HepB 1 - Total 0 0 0 9. OPV 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
5. DPT-HiB-HepB 2 - Total 0 0 0 10. IPV - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
16. FIC - Total 0 0 0 18. Td, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
17. CIC - Total 0 0 0 19. MR, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
C2. Nutrition Services
22. Newborns initiated on breastfeeding
immediately after birth lasting to 90 mins - 28. Infants 6-11 mos. old seen - Total
Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
23. Preterm/LBW infants given iron 29. Infants 6-11 mos. given 1 dose of
supplementation - Total 0 0 0 Vitamin A 100,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
24. Infants 6 mos. old seen - Total 0 0 0 30. Children 12-59 mos seen - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
25. Infants exclusively breastfed until 6th month - 31. Children 12-59 mos. old given 2
Total 0 0 0 doses of Vitamin A 200,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
26. Infants 6 mos. old initiated to complementary 32. Infant 6-11 months old who completed
feeding with continued breastfeeding - Total 0 0 0 MNP supplementation - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
27. Infants 6 mos. old initiated to complementary
feeding but no longer or never been breastfed 33. Children 12-23 mos. seen - Total
- Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
0
40. 1-19 y/o given 2 doses of deworming drug - 42. SAC, 5-9 y/o dewormed (2 doses) -
Total 0 0 0 Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
41. PSAC, 1-4 y/o dewormed (2 doses) - Total 0 0 0
• NHTS 0
• Non-NHTS 0
0
44. Sick Infants 6-11 mos. old seen - Total 47. Sick Children 12-59 mos. old
0 0 0 received Vitamin A - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
45. Sick Infants 6-11 mos. old received 48. Diarrhea cases 0-59 months old seen
Vitamin A - Total 0 0 0 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
49. Diarrhea cases 0-59 months old
46. Sick Children 12-59 mos. old seen - Total
0 0 0 received ORS - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
 To be submitted Qua
Section E. Infectious Disease Preven
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
E1. Filariasis Prevention and Control E2. Schistosomiasis Prevention and Contro
1. No. of individual examined for lymphatic 1. No. of people 5-65 y/o who ingested
filariasis - Total 0 MDA drugs - Total
2. No. of individual examined found positive for 2. No. of patients seen - Total
lymphatic filariasis - Total 0 3. No. of suspected cases seen
3. No. of lymphatic filariasis cases examined with 4. No. acute clinically diagnosed cases -
manifestation of either lymphedema,hydrocele, Total
elephantiasis - Total
0 5. No. of confirmed acute cases - Total
6. No. of chronic clinically diagnosed
cases - Total
Section F. _________________________
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
 ___JANUARY_____ YEAR: ____2020___

M1
AGPAKO__________________________
_________________________
_________________________

BRGY
________________________
________________________
r submission to RHU/MHC

Services and Deworming for Women of Reproductive Age

Total A3. Deworming Services SES Total

Col. 3) (Col. 1) (Col. 2) (Col. 3)

NHTS Non-NHTS
1. No. of women 20-49 years old given 2 doses of
15 deworming drugs - Total
0 0 0
15
0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
on B. Maternal Care and Services
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

a. Number of pregnant women seen in the

first trimester who have normal BMI -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of pregnant women seen in the first
trimester who have low BMI - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

7. No. of pregnant women given iodine

capsules – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
8. No. of pregnant women given one dose
of deworming tablet - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
9. No. of pregnant women screened for
syphilis - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
10. No. of pregnant women tested positive
for syphilis - Total

0 0 0 0
 • NHTS 0
• Non-NHTS 0
11. No. of pregnant women screened for
Hepatitis B - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
18. No. of deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
19. No. of live births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20a. No. of live births with normal birth
weight - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20b. No. of live births with low birth weight
- Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
20c. No. of live births with unknown birth
weight- Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
21. No. of deliveries attended by skilled
health professionals - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col 3)  (Col. 4)
rks Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

24a. No. of deliveries in public health

facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
24b. No. of deliveries in private health
facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
25. No. of non-facility-based deliveries -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
26a. No. of vaginal deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
26b. No. of deliveries by cesarean
section – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
27a. No. of full-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
27b. No. of pre-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B3. Postpartum and Newborn Care
28. No. of postpartum women together
with their newborn who completed at
least 2 postpartum check-ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
 29. No. of postpartum women who
completed iron with folic acid
supplementation - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
30. No. of postpartum women with
Vitamin A supplementation – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
ction C. Child Care and Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)

epB 3 - Total 0 0 0 11. PCV 1 - Total 0 0

0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 12. PCV 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 13. PCV 3 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 14. MMR 1 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
0 0 0 15. MMR 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
1 (November) - Total 0 0 0 20. Td, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
e 1 (November) - Total 0 0 0 21. MR, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

34. Children 12-23 mos. who completed

1 mos. old seen - Total
MNP supplementation - Total
0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
 1 mos. given 1 dose of
35. Children 0-59 mos. seen - Total
100,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos seen - Total 0 0 0 36. Stunted - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos. old given 2
37. Wasted - Total
tamin A 200,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
1 months old who completed
38. Overweight/Obese - Total
lementation - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS

2-23 mos. seen - Total 39. Normal - Total

0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col. 1) (Col 2) (Col 3)

y/o dewormed (2 doses) - 43. Adolescents, 10-19 y/o dewormed

0 0 0 (2 doses) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

ren 12-59 mos. old 50. Diarrhea cases 0-59 mos. received
itamin A - Total 0 0 0 ORS w/ zinc - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old seen 51. Pneumonia cases 0-59 mos. old
0 0 0 seen - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old 52. Pneumonia cases 0-59 mos. old
ORS - Total 0 0 0 completed treatment - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
 To be submitted Quarterly
ous Disease Prevention and Control Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
miasis Prevention and Control E2. Schistosomiasis Prevention and Control (Con't.)
le 5-65 y/o who ingested 7. No. confirmed chronic cases - Total
- Total 0
nts seen - Total 0 8. No. of confirmed cases (acute and
ected cases seen 0 chronic) - Total
clinically diagnosed cases - 9. No. of cases treated - Total
0
rmed acute cases - Total 0 10. No. of confirmed chronic cases
nic clinically diagnosed referred to a hospital facility - Total
al 0
_________________________________________
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
M1
RGY
Total

(Col. 3)

New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
 0 0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0 0
0
0
0 0
0
0
0 0
0
0
 0 0
0
0

Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
 Total
(Col 4)

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Total
(Col 4)
0
0
0
0
0
0

0
0
0
 0
0
0
0
0
0

0
0
0

0
0
0

0
0
0
Total
(Col 4)

0
0
0

0
0
0

0
0
0

0
0
0
 Total
(Col 4)
't.)

Total
(Col 4)
 FHSIS REPORT for the MONTH: ___JANUARY_____
Name of Barangay: _____TAGPAKO_________
Name of BHS: _______________________
Name of Municipality/City: _______________________
Name of Province: ________________________
Projected Population of the Year: _______________________
For submission to RHU/MHC

Section A. Family Planning Services and Dewor

A1. Modern FP Unmet Need Age Total

(Col. 1) (Col. 2) (Col. 3)

10-14 15-19 20-49
1. No. of WRA with unmet
need for modern FP - Total 5 5 5
15
• NHTS 5 5 5 15
• Non-NHTS 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
a. Female Sterilization/ BTL - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
b. Male Sterilization/ NSV-Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
c. Condom - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d. Pills - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
 d.1 Pills-POP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d.2 Pills-COC - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
e. Injectables (DMPA/ POI) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
f. Implant - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g. IUD (IUD-I and IUD-PP) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.1 IUD-I- Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.2 IUD-PP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
h. NFP-LAM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
i. NFP-BBT - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
j. NFP-CMM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
k. NFP-STM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
l. NFP-SDM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
m. Total Current Users 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
Section B. Maternal Care
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
1. No. of pregnant women w/
at least 4 prenatal check-
ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
2. No. of pregnant women
assessed of their nutritional
status during the 1st tri. -Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
c. No. of pregnant women
seen in the first trimester
who have high BMI - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
3. No. of pregnant women for
the first time given 2 doses of
Td vaccination - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
4. No. of pregnant women for
the 2nd or more times given
at least 3 doses of Td
vaccination (Td2 Plus) - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
5. No. of pregnant women who
completed the dose of iron
with folic acid
supplementation - Total 0 0 0 0
 • NHTS 0
• Non-NHTS 0
6. No. of pregnant women who
completed doses of calcium
carbonate supplementation -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
12. No. of pregnant women
tested positive for Hepatitis
B - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
13. No. of pregnant women
screened for HIV - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
14. No. of pregnant women
tested for CBC or Hgb&Hct
count - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
15. No. of pregnant women
tested for CBC or Hgb&Hct
count diagnosed with
anemia - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
16. No. of pregnant women
screened for gestational
diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
17.   No. of pregnant women
tested positive for
gestational diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col 3)  (Col. 4)
 Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
a. No. of deliveries attended
by a doctor - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by a nurse – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
c. No. of deliveries attended
by midwives - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
22. No. of deliveries attended by
non-skilled health
professionals - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
a. No. of deliveries attended
by Hilot/TBA - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by others - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
23. No. of health facility-based
deliveries - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
27c. No. of fetal deaths - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
27d. No. of abortion/
miscarriage - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0

Section C. Child Care a

Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
C1. Immunization Services
1. CPAB - Total 0 0 0 6. DPT-HiB-HepB 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
2. BCG - Total 0 0 0 7. OPV 1 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
3. HepB, within 24 hours. - Total 0 0 0 8. OPV 2 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
4. DPT-HiB-HepB 1 - Total 0 0 0 9. OPV 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
5. DPT-HiB-HepB 2 - Total 0 0 0 10. IPV - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
16. FIC - Total 0 0 0 18. Td, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
17. CIC - Total 0 0 0 19. MR, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
C2. Nutrition Services
22. Newborns initiated on breastfeeding
immediately after birth lasting to 90 mins - 28. Infants 6-11 mos. old seen - Total
Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
23. Preterm/LBW infants given iron 29. Infants 6-11 mos. given 1 dose of
supplementation - Total 0 0 0 Vitamin A 100,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
24. Infants 6 mos. old seen - Total 0 0 0 30. Children 12-59 mos seen - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
25. Infants exclusively breastfed until 6th month - 31. Children 12-59 mos. old given 2
Total 0 0 0 doses of Vitamin A 200,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
26. Infants 6 mos. old initiated to complementary 32. Infant 6-11 months old who completed
feeding with continued breastfeeding - Total 0 0 0 MNP supplementation - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
27. Infants 6 mos. old initiated to complementary
feeding but no longer or never been breastfed 33. Children 12-23 mos. seen - Total
- Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
0
40. 1-19 y/o given 2 doses of deworming drug - 42. SAC, 5-9 y/o dewormed (2 doses) -
Total 0 0 0 Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
41. PSAC, 1-4 y/o dewormed (2 doses) - Total 0 0 0
• NHTS 0
• Non-NHTS 0
0
44. Sick Infants 6-11 mos. old seen - Total 47. Sick Children 12-59 mos. old
0 0 0 received Vitamin A - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
45. Sick Infants 6-11 mos. old received 48. Diarrhea cases 0-59 months old seen
Vitamin A - Total 0 0 0 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
49. Diarrhea cases 0-59 months old
46. Sick Children 12-59 mos. old seen - Total
0 0 0 received ORS - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
 To be submitted Qua
Section E. Infectious Disease Preven
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
E1. Filariasis Prevention and Control E2. Schistosomiasis Prevention and Contro
1. No. of individual examined for lymphatic 1. No. of people 5-65 y/o who ingested
filariasis - Total 0 MDA drugs - Total
2. No. of individual examined found positive for 2. No. of patients seen - Total
lymphatic filariasis - Total 0 3. No. of suspected cases seen
3. No. of lymphatic filariasis cases examined with 4. No. acute clinically diagnosed cases -
manifestation of either lymphedema,hydrocele, Total
elephantiasis - Total
0 5. No. of confirmed acute cases - Total
6. No. of chronic clinically diagnosed
cases - Total
Section F. _________________________
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
 ___JANUARY_____ YEAR: ____2020___

M1
AGPAKO__________________________
_________________________
_________________________

BRGY
________________________
________________________
r submission to RHU/MHC

Services and Deworming for Women of Reproductive Age

Total A3. Deworming Services SES Total

Col. 3) (Col. 1) (Col. 2) (Col. 3)

NHTS Non-NHTS
1. No. of women 20-49 years old given 2 doses of
15 deworming drugs - Total
0 0 0
15
0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
on B. Maternal Care and Services
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

a. Number of pregnant women seen in the

first trimester who have normal BMI -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of pregnant women seen in the first
trimester who have low BMI - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

7. No. of pregnant women given iodine

capsules – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
8. No. of pregnant women given one dose
of deworming tablet - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
9. No. of pregnant women screened for
syphilis - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
10. No. of pregnant women tested positive
for syphilis - Total

0 0 0 0
 • NHTS 0
• Non-NHTS 0
11. No. of pregnant women screened for
Hepatitis B - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
18. No. of deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
19. No. of live births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20a. No. of live births with normal birth
weight - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20b. No. of live births with low birth weight
- Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
20c. No. of live births with unknown birth
weight- Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
21. No. of deliveries attended by skilled
health professionals - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col 3)  (Col. 4)
rks Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

24a. No. of deliveries in public health

facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
24b. No. of deliveries in private health
facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
25. No. of non-facility-based deliveries -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
26a. No. of vaginal deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
26b. No. of deliveries by cesarean
section – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
27a. No. of full-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
27b. No. of pre-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B3. Postpartum and Newborn Care
28. No. of postpartum women together
with their newborn who completed at
least 2 postpartum check-ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
 29. No. of postpartum women who
completed iron with folic acid
supplementation - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
30. No. of postpartum women with
Vitamin A supplementation – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
ction C. Child Care and Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)

epB 3 - Total 0 0 0 11. PCV 1 - Total 0 0

0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 12. PCV 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 13. PCV 3 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 14. MMR 1 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
0 0 0 15. MMR 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
1 (November) - Total 0 0 0 20. Td, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
e 1 (November) - Total 0 0 0 21. MR, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

34. Children 12-23 mos. who completed

1 mos. old seen - Total
MNP supplementation - Total
0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
 1 mos. given 1 dose of
35. Children 0-59 mos. seen - Total
100,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos seen - Total 0 0 0 36. Stunted - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos. old given 2
37. Wasted - Total
tamin A 200,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
1 months old who completed
38. Overweight/Obese - Total
lementation - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS

2-23 mos. seen - Total 39. Normal - Total

0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col. 1) (Col 2) (Col 3)

y/o dewormed (2 doses) - 43. Adolescents, 10-19 y/o dewormed

0 0 0 (2 doses) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

ren 12-59 mos. old 50. Diarrhea cases 0-59 mos. received
itamin A - Total 0 0 0 ORS w/ zinc - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old seen 51. Pneumonia cases 0-59 mos. old
0 0 0 seen - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old 52. Pneumonia cases 0-59 mos. old
ORS - Total 0 0 0 completed treatment - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
 To be submitted Quarterly
ous Disease Prevention and Control Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
miasis Prevention and Control E2. Schistosomiasis Prevention and Control (Con't.)
le 5-65 y/o who ingested 7. No. confirmed chronic cases - Total
- Total 0
nts seen - Total 0 8. No. of confirmed cases (acute and
ected cases seen 0 chronic) - Total
clinically diagnosed cases - 9. No. of cases treated - Total
0
rmed acute cases - Total 0 10. No. of confirmed chronic cases
nic clinically diagnosed referred to a hospital facility - Total
al 0
_________________________________________
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
M1
RGY
Total

(Col. 3)

New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
 0 0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0 0
0
0
0 0
0
0
0 0
0
0
 0 0
0
0

Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
 Total
(Col 4)

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Total
(Col 4)
0
0
0
0
0
0

0
0
0
 0
0
0
0
0
0

0
0
0

0
0
0

0
0
0
Total
(Col 4)

0
0
0

0
0
0

0
0
0

0
0
0
 Total
(Col 4)
't.)

Total
(Col 4)
 FHSIS REPORT for the MONTH: ___JANUARY_____
Name of Barangay: _____TAGPAKO_________
Name of BHS: _______________________
Name of Municipality/City: _______________________
Name of Province: ________________________
Projected Population of the Year: _______________________
For submission to RHU/MHC

Section A. Family Planning Services and Dewor

A1. Modern FP Unmet Need Age Total

(Col. 1) (Col. 2) (Col. 3)

10-14 15-19 20-49
1. No. of WRA with unmet
need for modern FP - Total 5 5 5
15
• NHTS 5 5 5 15
• Non-NHTS 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
a. Female Sterilization/ BTL - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
b. Male Sterilization/ NSV-Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
c. Condom - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d. Pills - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
 d.1 Pills-POP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d.2 Pills-COC - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
e. Injectables (DMPA/ POI) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
f. Implant - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g. IUD (IUD-I and IUD-PP) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.1 IUD-I- Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.2 IUD-PP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
h. NFP-LAM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
i. NFP-BBT - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
j. NFP-CMM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
k. NFP-STM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
l. NFP-SDM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
m. Total Current Users 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
Section B. Maternal Care
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
1. No. of pregnant women w/
at least 4 prenatal check-
ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
2. No. of pregnant women
assessed of their nutritional
status during the 1st tri. -Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
c. No. of pregnant women
seen in the first trimester
who have high BMI - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
3. No. of pregnant women for
the first time given 2 doses of
Td vaccination - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
4. No. of pregnant women for
the 2nd or more times given
at least 3 doses of Td
vaccination (Td2 Plus) - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
5. No. of pregnant women who
completed the dose of iron
with folic acid
supplementation - Total 0 0 0 0
 • NHTS 0
• Non-NHTS 0
6. No. of pregnant women who
completed doses of calcium
carbonate supplementation -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
12. No. of pregnant women
tested positive for Hepatitis
B - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
13. No. of pregnant women
screened for HIV - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
14. No. of pregnant women
tested for CBC or Hgb&Hct
count - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
15. No. of pregnant women
tested for CBC or Hgb&Hct
count diagnosed with
anemia - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
16. No. of pregnant women
screened for gestational
diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
17.   No. of pregnant women
tested positive for
gestational diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col 3)  (Col. 4)
 Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
a. No. of deliveries attended
by a doctor - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by a nurse – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
c. No. of deliveries attended
by midwives - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
22. No. of deliveries attended by
non-skilled health
professionals - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
a. No. of deliveries attended
by Hilot/TBA - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by others - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
23. No. of health facility-based
deliveries - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
27c. No. of fetal deaths - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
27d. No. of abortion/
miscarriage - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0

Section C. Child Care a

Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
C1. Immunization Services
1. CPAB - Total 0 0 0 6. DPT-HiB-HepB 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
2. BCG - Total 0 0 0 7. OPV 1 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
3. HepB, within 24 hours. - Total 0 0 0 8. OPV 2 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
4. DPT-HiB-HepB 1 - Total 0 0 0 9. OPV 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
5. DPT-HiB-HepB 2 - Total 0 0 0 10. IPV - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
16. FIC - Total 0 0 0 18. Td, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
17. CIC - Total 0 0 0 19. MR, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
C2. Nutrition Services
22. Newborns initiated on breastfeeding
immediately after birth lasting to 90 mins - 28. Infants 6-11 mos. old seen - Total
Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
23. Preterm/LBW infants given iron 29. Infants 6-11 mos. given 1 dose of
supplementation - Total 0 0 0 Vitamin A 100,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
24. Infants 6 mos. old seen - Total 0 0 0 30. Children 12-59 mos seen - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
25. Infants exclusively breastfed until 6th month - 31. Children 12-59 mos. old given 2
Total 0 0 0 doses of Vitamin A 200,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
26. Infants 6 mos. old initiated to complementary 32. Infant 6-11 months old who completed
feeding with continued breastfeeding - Total 0 0 0 MNP supplementation - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
27. Infants 6 mos. old initiated to complementary
feeding but no longer or never been breastfed 33. Children 12-23 mos. seen - Total
- Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
0
40. 1-19 y/o given 2 doses of deworming drug - 42. SAC, 5-9 y/o dewormed (2 doses) -
Total 0 0 0 Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
41. PSAC, 1-4 y/o dewormed (2 doses) - Total 0 0 0
• NHTS 0
• Non-NHTS 0
0
44. Sick Infants 6-11 mos. old seen - Total 47. Sick Children 12-59 mos. old
0 0 0 received Vitamin A - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
45. Sick Infants 6-11 mos. old received 48. Diarrhea cases 0-59 months old seen
Vitamin A - Total 0 0 0 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
49. Diarrhea cases 0-59 months old
46. Sick Children 12-59 mos. old seen - Total
0 0 0 received ORS - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
 To be submitted Qua
Section E. Infectious Disease Preven
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
E1. Filariasis Prevention and Control E2. Schistosomiasis Prevention and Contro
1. No. of individual examined for lymphatic 1. No. of people 5-65 y/o who ingested
filariasis - Total 0 MDA drugs - Total
2. No. of individual examined found positive for 2. No. of patients seen - Total
lymphatic filariasis - Total 0 3. No. of suspected cases seen
3. No. of lymphatic filariasis cases examined with 4. No. acute clinically diagnosed cases -
manifestation of either lymphedema,hydrocele, Total
elephantiasis - Total
0 5. No. of confirmed acute cases - Total
6. No. of chronic clinically diagnosed
cases - Total
Section F. _________________________
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
 ___JANUARY_____ YEAR: ____2020___

M1
AGPAKO__________________________
_________________________
_________________________

BRGY
________________________
________________________
r submission to RHU/MHC

Services and Deworming for Women of Reproductive Age

Total A3. Deworming Services SES Total

Col. 3) (Col. 1) (Col. 2) (Col. 3)

NHTS Non-NHTS
1. No. of women 20-49 years old given 2 doses of
15 deworming drugs - Total
0 0 0
15
0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
on B. Maternal Care and Services
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

a. Number of pregnant women seen in the

first trimester who have normal BMI -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of pregnant women seen in the first
trimester who have low BMI - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

7. No. of pregnant women given iodine

capsules – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
8. No. of pregnant women given one dose
of deworming tablet - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
9. No. of pregnant women screened for
syphilis - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
10. No. of pregnant women tested positive
for syphilis - Total

0 0 0 0
 • NHTS 0
• Non-NHTS 0
11. No. of pregnant women screened for
Hepatitis B - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
18. No. of deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
19. No. of live births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20a. No. of live births with normal birth
weight - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20b. No. of live births with low birth weight
- Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
20c. No. of live births with unknown birth
weight- Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
21. No. of deliveries attended by skilled
health professionals - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col 3)  (Col. 4)
rks Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

24a. No. of deliveries in public health

facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
24b. No. of deliveries in private health
facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
25. No. of non-facility-based deliveries -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
26a. No. of vaginal deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
26b. No. of deliveries by cesarean
section – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
27a. No. of full-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
27b. No. of pre-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B3. Postpartum and Newborn Care
28. No. of postpartum women together
with their newborn who completed at
least 2 postpartum check-ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
 29. No. of postpartum women who
completed iron with folic acid
supplementation - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
30. No. of postpartum women with
Vitamin A supplementation – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
ction C. Child Care and Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)

epB 3 - Total 0 0 0 11. PCV 1 - Total 0 0

0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 12. PCV 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 13. PCV 3 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 14. MMR 1 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
0 0 0 15. MMR 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
1 (November) - Total 0 0 0 20. Td, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
e 1 (November) - Total 0 0 0 21. MR, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

34. Children 12-23 mos. who completed

1 mos. old seen - Total
MNP supplementation - Total
0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
 1 mos. given 1 dose of
35. Children 0-59 mos. seen - Total
100,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos seen - Total 0 0 0 36. Stunted - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos. old given 2
37. Wasted - Total
tamin A 200,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
1 months old who completed
38. Overweight/Obese - Total
lementation - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS

2-23 mos. seen - Total 39. Normal - Total

0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col. 1) (Col 2) (Col 3)

y/o dewormed (2 doses) - 43. Adolescents, 10-19 y/o dewormed

0 0 0 (2 doses) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

ren 12-59 mos. old 50. Diarrhea cases 0-59 mos. received
itamin A - Total 0 0 0 ORS w/ zinc - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old seen 51. Pneumonia cases 0-59 mos. old
0 0 0 seen - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old 52. Pneumonia cases 0-59 mos. old
ORS - Total 0 0 0 completed treatment - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
 To be submitted Quarterly
ous Disease Prevention and Control Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
miasis Prevention and Control E2. Schistosomiasis Prevention and Control (Con't.)
le 5-65 y/o who ingested 7. No. confirmed chronic cases - Total
- Total 0
nts seen - Total 0 8. No. of confirmed cases (acute and
ected cases seen 0 chronic) - Total
clinically diagnosed cases - 9. No. of cases treated - Total
0
rmed acute cases - Total 0 10. No. of confirmed chronic cases
nic clinically diagnosed referred to a hospital facility - Total
al 0
_________________________________________
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
M1
RGY
Total

(Col. 3)

New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
 0 0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0 0
0
0
0 0
0
0
0 0
0
0
 0 0
0
0

Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
 Total
(Col 4)

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Total
(Col 4)
0
0
0
0
0
0

0
0
0
 0
0
0
0
0
0

0
0
0

0
0
0

0
0
0
Total
(Col 4)

0
0
0

0
0
0

0
0
0

0
0
0
 Total
(Col 4)
't.)

Total
(Col 4)
 FHSIS REPORT for the MONTH: ___JANUARY_____
Name of Barangay: _____TAGPAKO_________
Name of BHS: _______________________
Name of Municipality/City: _______________________
Name of Province: ________________________
Projected Population of the Year: _______________________
For submission to RHU/MHC

Section A. Family Planning Services and Dewor

A1. Modern FP Unmet Need Age Total

(Col. 1) (Col. 2) (Col. 3)

10-14 15-19 20-49
1. No. of WRA with unmet
need for modern FP - Total 5 5 5
15
• NHTS 5 5 5 15
• Non-NHTS 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
a. Female Sterilization/ BTL - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
b. Male Sterilization/ NSV-Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
c. Condom - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d. Pills - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
 d.1 Pills-POP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d.2 Pills-COC - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
e. Injectables (DMPA/ POI) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
f. Implant - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g. IUD (IUD-I and IUD-PP) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.1 IUD-I- Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.2 IUD-PP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
h. NFP-LAM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
i. NFP-BBT - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
j. NFP-CMM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
k. NFP-STM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
l. NFP-SDM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
m. Total Current Users 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
Section B. Maternal Care
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
1. No. of pregnant women w/
at least 4 prenatal check-
ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
2. No. of pregnant women
assessed of their nutritional
status during the 1st tri. -Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
c. No. of pregnant women
seen in the first trimester
who have high BMI - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
3. No. of pregnant women for
the first time given 2 doses of
Td vaccination - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
4. No. of pregnant women for
the 2nd or more times given
at least 3 doses of Td
vaccination (Td2 Plus) - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
5. No. of pregnant women who
completed the dose of iron
with folic acid
supplementation - Total 0 0 0 0
 • NHTS 0
• Non-NHTS 0
6. No. of pregnant women who
completed doses of calcium
carbonate supplementation -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
12. No. of pregnant women
tested positive for Hepatitis
B - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
13. No. of pregnant women
screened for HIV - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
14. No. of pregnant women
tested for CBC or Hgb&Hct
count - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
15. No. of pregnant women
tested for CBC or Hgb&Hct
count diagnosed with
anemia - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
16. No. of pregnant women
screened for gestational
diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
17.   No. of pregnant women
tested positive for
gestational diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col 3)  (Col. 4)
 Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
a. No. of deliveries attended
by a doctor - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by a nurse – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
c. No. of deliveries attended
by midwives - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
22. No. of deliveries attended by
non-skilled health
professionals - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
a. No. of deliveries attended
by Hilot/TBA - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by others - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
23. No. of health facility-based
deliveries - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
27c. No. of fetal deaths - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
27d. No. of abortion/
miscarriage - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0

Section C. Child Care a

Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
C1. Immunization Services
1. CPAB - Total 0 0 0 6. DPT-HiB-HepB 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
2. BCG - Total 0 0 0 7. OPV 1 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
3. HepB, within 24 hours. - Total 0 0 0 8. OPV 2 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
4. DPT-HiB-HepB 1 - Total 0 0 0 9. OPV 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
5. DPT-HiB-HepB 2 - Total 0 0 0 10. IPV - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
16. FIC - Total 0 0 0 18. Td, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
17. CIC - Total 0 0 0 19. MR, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
C2. Nutrition Services
22. Newborns initiated on breastfeeding
immediately after birth lasting to 90 mins - 28. Infants 6-11 mos. old seen - Total
Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
23. Preterm/LBW infants given iron 29. Infants 6-11 mos. given 1 dose of
supplementation - Total 0 0 0 Vitamin A 100,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
24. Infants 6 mos. old seen - Total 0 0 0 30. Children 12-59 mos seen - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
25. Infants exclusively breastfed until 6th month - 31. Children 12-59 mos. old given 2
Total 0 0 0 doses of Vitamin A 200,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
26. Infants 6 mos. old initiated to complementary 32. Infant 6-11 months old who completed
feeding with continued breastfeeding - Total 0 0 0 MNP supplementation - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
27. Infants 6 mos. old initiated to complementary
feeding but no longer or never been breastfed 33. Children 12-23 mos. seen - Total
- Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
0
40. 1-19 y/o given 2 doses of deworming drug - 42. SAC, 5-9 y/o dewormed (2 doses) -
Total 0 0 0 Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
41. PSAC, 1-4 y/o dewormed (2 doses) - Total 0 0 0
• NHTS 0
• Non-NHTS 0
0
44. Sick Infants 6-11 mos. old seen - Total 47. Sick Children 12-59 mos. old
0 0 0 received Vitamin A - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
45. Sick Infants 6-11 mos. old received 48. Diarrhea cases 0-59 months old seen
Vitamin A - Total 0 0 0 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
49. Diarrhea cases 0-59 months old
46. Sick Children 12-59 mos. old seen - Total
0 0 0 received ORS - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
 To be submitted Qua
Section E. Infectious Disease Preven
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
E1. Filariasis Prevention and Control E2. Schistosomiasis Prevention and Contro
1. No. of individual examined for lymphatic 1. No. of people 5-65 y/o who ingested
filariasis - Total 0 MDA drugs - Total
2. No. of individual examined found positive for 2. No. of patients seen - Total
lymphatic filariasis - Total 0 3. No. of suspected cases seen
3. No. of lymphatic filariasis cases examined with 4. No. acute clinically diagnosed cases -
manifestation of either lymphedema,hydrocele, Total
elephantiasis - Total
0 5. No. of confirmed acute cases - Total
6. No. of chronic clinically diagnosed
cases - Total
Section F. _________________________
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
 ___JANUARY_____ YEAR: ____2020___

M1
AGPAKO__________________________
_________________________
_________________________

BRGY
________________________
________________________
r submission to RHU/MHC

Services and Deworming for Women of Reproductive Age

Total A3. Deworming Services SES Total

Col. 3) (Col. 1) (Col. 2) (Col. 3)

NHTS Non-NHTS
1. No. of women 20-49 years old given 2 doses of
15 deworming drugs - Total
0 0 0
15
0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
on B. Maternal Care and Services
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

a. Number of pregnant women seen in the

first trimester who have normal BMI -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of pregnant women seen in the first
trimester who have low BMI - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

7. No. of pregnant women given iodine

capsules – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
8. No. of pregnant women given one dose
of deworming tablet - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
9. No. of pregnant women screened for
syphilis - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
10. No. of pregnant women tested positive
for syphilis - Total

0 0 0 0
 • NHTS 0
• Non-NHTS 0
11. No. of pregnant women screened for
Hepatitis B - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
18. No. of deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
19. No. of live births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20a. No. of live births with normal birth
weight - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20b. No. of live births with low birth weight
- Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
20c. No. of live births with unknown birth
weight- Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
21. No. of deliveries attended by skilled
health professionals - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col 3)  (Col. 4)
rks Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

24a. No. of deliveries in public health

facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
24b. No. of deliveries in private health
facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
25. No. of non-facility-based deliveries -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
26a. No. of vaginal deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
26b. No. of deliveries by cesarean
section – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
27a. No. of full-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
27b. No. of pre-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B3. Postpartum and Newborn Care
28. No. of postpartum women together
with their newborn who completed at
least 2 postpartum check-ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
 29. No. of postpartum women who
completed iron with folic acid
supplementation - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
30. No. of postpartum women with
Vitamin A supplementation – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
ction C. Child Care and Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)

epB 3 - Total 0 0 0 11. PCV 1 - Total 0 0

0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 12. PCV 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 13. PCV 3 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 14. MMR 1 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
0 0 0 15. MMR 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
1 (November) - Total 0 0 0 20. Td, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
e 1 (November) - Total 0 0 0 21. MR, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

34. Children 12-23 mos. who completed

1 mos. old seen - Total
MNP supplementation - Total
0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
 1 mos. given 1 dose of
35. Children 0-59 mos. seen - Total
100,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos seen - Total 0 0 0 36. Stunted - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos. old given 2
37. Wasted - Total
tamin A 200,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
1 months old who completed
38. Overweight/Obese - Total
lementation - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS

2-23 mos. seen - Total 39. Normal - Total

0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col. 1) (Col 2) (Col 3)

y/o dewormed (2 doses) - 43. Adolescents, 10-19 y/o dewormed

0 0 0 (2 doses) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

ren 12-59 mos. old 50. Diarrhea cases 0-59 mos. received
itamin A - Total 0 0 0 ORS w/ zinc - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old seen 51. Pneumonia cases 0-59 mos. old
0 0 0 seen - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old 52. Pneumonia cases 0-59 mos. old
ORS - Total 0 0 0 completed treatment - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
 To be submitted Quarterly
ous Disease Prevention and Control Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
miasis Prevention and Control E2. Schistosomiasis Prevention and Control (Con't.)
le 5-65 y/o who ingested 7. No. confirmed chronic cases - Total
- Total 0
nts seen - Total 0 8. No. of confirmed cases (acute and
ected cases seen 0 chronic) - Total
clinically diagnosed cases - 9. No. of cases treated - Total
0
rmed acute cases - Total 0 10. No. of confirmed chronic cases
nic clinically diagnosed referred to a hospital facility - Total
al 0
_________________________________________
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
M1
RGY
Total

(Col. 3)

New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
 0 0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0 0
0
0
0 0
0
0
0 0
0
0
 0 0
0
0

Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
 Total
(Col 4)

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Total
(Col 4)
0
0
0
0
0
0

0
0
0
 0
0
0
0
0
0

0
0
0

0
0
0

0
0
0
Total
(Col 4)

0
0
0

0
0
0

0
0
0

0
0
0
 Total
(Col 4)
't.)

Total
(Col 4)
 FHSIS REPORT for the MONTH: ___JANUARY_____
Name of Barangay: _____TAGPAKO_________
Name of BHS: _______________________
Name of Municipality/City: _______________________
Name of Province: ________________________
Projected Population of the Year: _______________________
For submission to RHU/MHC

Section A. Family Planning Services and Dewor

A1. Modern FP Unmet Need Age Total

(Col. 1) (Col. 2) (Col. 3)

10-14 15-19 20-49
1. No. of WRA with unmet
need for modern FP - Total 5 5 5
15
• NHTS 5 5 5 15
• Non-NHTS 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
a. Female Sterilization/ BTL - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
b. Male Sterilization/ NSV-Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
c. Condom - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d. Pills - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
 d.1 Pills-POP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d.2 Pills-COC - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
e. Injectables (DMPA/ POI) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
f. Implant - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g. IUD (IUD-I and IUD-PP) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.1 IUD-I- Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.2 IUD-PP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
h. NFP-LAM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
i. NFP-BBT - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
j. NFP-CMM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
k. NFP-STM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
l. NFP-SDM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
m. Total Current Users 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
Section B. Maternal Care
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
1. No. of pregnant women w/
at least 4 prenatal check-
ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
2. No. of pregnant women
assessed of their nutritional
status during the 1st tri. -Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
c. No. of pregnant women
seen in the first trimester
who have high BMI - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
3. No. of pregnant women for
the first time given 2 doses of
Td vaccination - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
4. No. of pregnant women for
the 2nd or more times given
at least 3 doses of Td
vaccination (Td2 Plus) - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
5. No. of pregnant women who
completed the dose of iron
with folic acid
supplementation - Total 0 0 0 0
 • NHTS 0
• Non-NHTS 0
6. No. of pregnant women who
completed doses of calcium
carbonate supplementation -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
12. No. of pregnant women
tested positive for Hepatitis
B - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
13. No. of pregnant women
screened for HIV - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
14. No. of pregnant women
tested for CBC or Hgb&Hct
count - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
15. No. of pregnant women
tested for CBC or Hgb&Hct
count diagnosed with
anemia - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
16. No. of pregnant women
screened for gestational
diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
17.   No. of pregnant women
tested positive for
gestational diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col 3)  (Col. 4)
 Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
a. No. of deliveries attended
by a doctor - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by a nurse – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
c. No. of deliveries attended
by midwives - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
22. No. of deliveries attended by
non-skilled health
professionals - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
a. No. of deliveries attended
by Hilot/TBA - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by others - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
23. No. of health facility-based
deliveries - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
27c. No. of fetal deaths - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
27d. No. of abortion/
miscarriage - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0

Section C. Child Care a

Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
C1. Immunization Services
1. CPAB - Total 0 0 0 6. DPT-HiB-HepB 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
2. BCG - Total 0 0 0 7. OPV 1 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
3. HepB, within 24 hours. - Total 0 0 0 8. OPV 2 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
4. DPT-HiB-HepB 1 - Total 0 0 0 9. OPV 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
5. DPT-HiB-HepB 2 - Total 0 0 0 10. IPV - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
16. FIC - Total 0 0 0 18. Td, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
17. CIC - Total 0 0 0 19. MR, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
C2. Nutrition Services
22. Newborns initiated on breastfeeding
immediately after birth lasting to 90 mins - 28. Infants 6-11 mos. old seen - Total
Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
23. Preterm/LBW infants given iron 29. Infants 6-11 mos. given 1 dose of
supplementation - Total 0 0 0 Vitamin A 100,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
24. Infants 6 mos. old seen - Total 0 0 0 30. Children 12-59 mos seen - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
25. Infants exclusively breastfed until 6th month - 31. Children 12-59 mos. old given 2
Total 0 0 0 doses of Vitamin A 200,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
26. Infants 6 mos. old initiated to complementary 32. Infant 6-11 months old who completed
feeding with continued breastfeeding - Total 0 0 0 MNP supplementation - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
27. Infants 6 mos. old initiated to complementary
feeding but no longer or never been breastfed 33. Children 12-23 mos. seen - Total
- Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
0
40. 1-19 y/o given 2 doses of deworming drug - 42. SAC, 5-9 y/o dewormed (2 doses) -
Total 0 0 0 Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
41. PSAC, 1-4 y/o dewormed (2 doses) - Total 0 0 0
• NHTS 0
• Non-NHTS 0
0
44. Sick Infants 6-11 mos. old seen - Total 47. Sick Children 12-59 mos. old
0 0 0 received Vitamin A - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
45. Sick Infants 6-11 mos. old received 48. Diarrhea cases 0-59 months old seen
Vitamin A - Total 0 0 0 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
49. Diarrhea cases 0-59 months old
46. Sick Children 12-59 mos. old seen - Total
0 0 0 received ORS - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
 To be submitted Qua
Section E. Infectious Disease Preven
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
E1. Filariasis Prevention and Control E2. Schistosomiasis Prevention and Contro
1. No. of individual examined for lymphatic 1. No. of people 5-65 y/o who ingested
filariasis - Total 0 MDA drugs - Total
2. No. of individual examined found positive for 2. No. of patients seen - Total
lymphatic filariasis - Total 0 3. No. of suspected cases seen
3. No. of lymphatic filariasis cases examined with 4. No. acute clinically diagnosed cases -
manifestation of either lymphedema,hydrocele, Total
elephantiasis - Total
0 5. No. of confirmed acute cases - Total
6. No. of chronic clinically diagnosed
cases - Total
Section F. _________________________
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
 ___JANUARY_____ YEAR: ____2020___

M1
AGPAKO__________________________
_________________________
_________________________

BRGY
________________________
________________________
r submission to RHU/MHC

Services and Deworming for Women of Reproductive Age

Total A3. Deworming Services SES Total

Col. 3) (Col. 1) (Col. 2) (Col. 3)

NHTS Non-NHTS
1. No. of women 20-49 years old given 2 doses of
15 deworming drugs - Total
0 0 0
15
0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
on B. Maternal Care and Services
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

a. Number of pregnant women seen in the

first trimester who have normal BMI -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of pregnant women seen in the first
trimester who have low BMI - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

7. No. of pregnant women given iodine

capsules – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
8. No. of pregnant women given one dose
of deworming tablet - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
9. No. of pregnant women screened for
syphilis - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
10. No. of pregnant women tested positive
for syphilis - Total

0 0 0 0
 • NHTS 0
• Non-NHTS 0
11. No. of pregnant women screened for
Hepatitis B - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
18. No. of deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
19. No. of live births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20a. No. of live births with normal birth
weight - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20b. No. of live births with low birth weight
- Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
20c. No. of live births with unknown birth
weight- Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
21. No. of deliveries attended by skilled
health professionals - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col 3)  (Col. 4)
rks Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

24a. No. of deliveries in public health

facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
24b. No. of deliveries in private health
facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
25. No. of non-facility-based deliveries -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
26a. No. of vaginal deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
26b. No. of deliveries by cesarean
section – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
27a. No. of full-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
27b. No. of pre-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B3. Postpartum and Newborn Care
28. No. of postpartum women together
with their newborn who completed at
least 2 postpartum check-ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
 29. No. of postpartum women who
completed iron with folic acid
supplementation - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
30. No. of postpartum women with
Vitamin A supplementation – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
ction C. Child Care and Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)

epB 3 - Total 0 0 0 11. PCV 1 - Total 0 0

0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 12. PCV 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 13. PCV 3 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 14. MMR 1 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
0 0 0 15. MMR 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
1 (November) - Total 0 0 0 20. Td, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
e 1 (November) - Total 0 0 0 21. MR, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

34. Children 12-23 mos. who completed

1 mos. old seen - Total
MNP supplementation - Total
0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
 1 mos. given 1 dose of
35. Children 0-59 mos. seen - Total
100,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos seen - Total 0 0 0 36. Stunted - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos. old given 2
37. Wasted - Total
tamin A 200,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
1 months old who completed
38. Overweight/Obese - Total
lementation - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS

2-23 mos. seen - Total 39. Normal - Total

0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col. 1) (Col 2) (Col 3)

y/o dewormed (2 doses) - 43. Adolescents, 10-19 y/o dewormed

0 0 0 (2 doses) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

ren 12-59 mos. old 50. Diarrhea cases 0-59 mos. received
itamin A - Total 0 0 0 ORS w/ zinc - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old seen 51. Pneumonia cases 0-59 mos. old
0 0 0 seen - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old 52. Pneumonia cases 0-59 mos. old
ORS - Total 0 0 0 completed treatment - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
 To be submitted Quarterly
ous Disease Prevention and Control Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
miasis Prevention and Control E2. Schistosomiasis Prevention and Control (Con't.)
le 5-65 y/o who ingested 7. No. confirmed chronic cases - Total
- Total 0
nts seen - Total 0 8. No. of confirmed cases (acute and
ected cases seen 0 chronic) - Total
clinically diagnosed cases - 9. No. of cases treated - Total
0
rmed acute cases - Total 0 10. No. of confirmed chronic cases
nic clinically diagnosed referred to a hospital facility - Total
al 0
_________________________________________
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
M1
RGY
Total

(Col. 3)

New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
 0 0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0 0
0
0
0 0
0
0
0 0
0
0
 0 0
0
0

Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
 Total
(Col 4)

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Total
(Col 4)
0
0
0
0
0
0

0
0
0
 0
0
0
0
0
0

0
0
0

0
0
0

0
0
0
Total
(Col 4)

0
0
0

0
0
0

0
0
0

0
0
0
 Total
(Col 4)
't.)

Total
(Col 4)
 FHSIS REPORT for the MONTH: ___JANUARY_____
Name of Barangay: _____TAGPAKO_________
Name of BHS: _______________________
Name of Municipality/City: _______________________
Name of Province: ________________________
Projected Population of the Year: _______________________
For submission to RHU/MHC

Section A. Family Planning Services and Dewor

A1. Modern FP Unmet Need Age Total

(Col. 1) (Col. 2) (Col. 3)

10-14 15-19 20-49
1. No. of WRA with unmet
need for modern FP - Total 5 5 5
15
• NHTS 5 5 5 15
• Non-NHTS 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
a. Female Sterilization/ BTL - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
b. Male Sterilization/ NSV-Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
c. Condom - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d. Pills - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
 d.1 Pills-POP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d.2 Pills-COC - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
e. Injectables (DMPA/ POI) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
f. Implant - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g. IUD (IUD-I and IUD-PP) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.1 IUD-I- Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.2 IUD-PP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
h. NFP-LAM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
i. NFP-BBT - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
j. NFP-CMM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
k. NFP-STM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
l. NFP-SDM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
m. Total Current Users 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
Section B. Maternal Care
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
1. No. of pregnant women w/
at least 4 prenatal check-
ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
2. No. of pregnant women
assessed of their nutritional
status during the 1st tri. -Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
c. No. of pregnant women
seen in the first trimester
who have high BMI - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
3. No. of pregnant women for
the first time given 2 doses of
Td vaccination - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
4. No. of pregnant women for
the 2nd or more times given
at least 3 doses of Td
vaccination (Td2 Plus) - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
5. No. of pregnant women who
completed the dose of iron
with folic acid
supplementation - Total 0 0 0 0
 • NHTS 0
• Non-NHTS 0
6. No. of pregnant women who
completed doses of calcium
carbonate supplementation -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
12. No. of pregnant women
tested positive for Hepatitis
B - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
13. No. of pregnant women
screened for HIV - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
14. No. of pregnant women
tested for CBC or Hgb&Hct
count - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
15. No. of pregnant women
tested for CBC or Hgb&Hct
count diagnosed with
anemia - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
16. No. of pregnant women
screened for gestational
diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
17.   No. of pregnant women
tested positive for
gestational diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col 3)  (Col. 4)
 Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
a. No. of deliveries attended
by a doctor - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by a nurse – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
c. No. of deliveries attended
by midwives - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
22. No. of deliveries attended by
non-skilled health
professionals - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
a. No. of deliveries attended
by Hilot/TBA - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by others - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
23. No. of health facility-based
deliveries - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
27c. No. of fetal deaths - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
27d. No. of abortion/
miscarriage - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0

Section C. Child Care a

Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
C1. Immunization Services
1. CPAB - Total 0 0 0 6. DPT-HiB-HepB 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
2. BCG - Total 0 0 0 7. OPV 1 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
3. HepB, within 24 hours. - Total 0 0 0 8. OPV 2 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
4. DPT-HiB-HepB 1 - Total 0 0 0 9. OPV 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
5. DPT-HiB-HepB 2 - Total 0 0 0 10. IPV - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
16. FIC - Total 0 0 0 18. Td, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
17. CIC - Total 0 0 0 19. MR, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
C2. Nutrition Services
22. Newborns initiated on breastfeeding
immediately after birth lasting to 90 mins - 28. Infants 6-11 mos. old seen - Total
Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
23. Preterm/LBW infants given iron 29. Infants 6-11 mos. given 1 dose of
supplementation - Total 0 0 0 Vitamin A 100,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
24. Infants 6 mos. old seen - Total 0 0 0 30. Children 12-59 mos seen - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
25. Infants exclusively breastfed until 6th month - 31. Children 12-59 mos. old given 2
Total 0 0 0 doses of Vitamin A 200,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
26. Infants 6 mos. old initiated to complementary 32. Infant 6-11 months old who completed
feeding with continued breastfeeding - Total 0 0 0 MNP supplementation - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
27. Infants 6 mos. old initiated to complementary
feeding but no longer or never been breastfed 33. Children 12-23 mos. seen - Total
- Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
0
40. 1-19 y/o given 2 doses of deworming drug - 42. SAC, 5-9 y/o dewormed (2 doses) -
Total 0 0 0 Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
41. PSAC, 1-4 y/o dewormed (2 doses) - Total 0 0 0
• NHTS 0
• Non-NHTS 0
0
44. Sick Infants 6-11 mos. old seen - Total 47. Sick Children 12-59 mos. old
0 0 0 received Vitamin A - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
45. Sick Infants 6-11 mos. old received 48. Diarrhea cases 0-59 months old seen
Vitamin A - Total 0 0 0 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
49. Diarrhea cases 0-59 months old
46. Sick Children 12-59 mos. old seen - Total
0 0 0 received ORS - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
 To be submitted Qua
Section E. Infectious Disease Preven
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
E1. Filariasis Prevention and Control E2. Schistosomiasis Prevention and Contro
1. No. of individual examined for lymphatic 1. No. of people 5-65 y/o who ingested
filariasis - Total 0 MDA drugs - Total
2. No. of individual examined found positive for 2. No. of patients seen - Total
lymphatic filariasis - Total 0 3. No. of suspected cases seen
3. No. of lymphatic filariasis cases examined with 4. No. acute clinically diagnosed cases -
manifestation of either lymphedema,hydrocele, Total
elephantiasis - Total
0 5. No. of confirmed acute cases - Total
6. No. of chronic clinically diagnosed
cases - Total
Section F. _________________________
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
 ___JANUARY_____ YEAR: ____2020___

M1
AGPAKO__________________________
_________________________
_________________________

BRGY
________________________
________________________
r submission to RHU/MHC

Services and Deworming for Women of Reproductive Age

Total A3. Deworming Services SES Total

Col. 3) (Col. 1) (Col. 2) (Col. 3)

NHTS Non-NHTS
1. No. of women 20-49 years old given 2 doses of
15 deworming drugs - Total
0 0 0
15
0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
on B. Maternal Care and Services
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

a. Number of pregnant women seen in the

first trimester who have normal BMI -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of pregnant women seen in the first
trimester who have low BMI - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

7. No. of pregnant women given iodine

capsules – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
8. No. of pregnant women given one dose
of deworming tablet - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
9. No. of pregnant women screened for
syphilis - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
10. No. of pregnant women tested positive
for syphilis - Total

0 0 0 0
 • NHTS 0
• Non-NHTS 0
11. No. of pregnant women screened for
Hepatitis B - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
18. No. of deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
19. No. of live births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20a. No. of live births with normal birth
weight - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20b. No. of live births with low birth weight
- Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
20c. No. of live births with unknown birth
weight- Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
21. No. of deliveries attended by skilled
health professionals - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col 3)  (Col. 4)
rks Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

24a. No. of deliveries in public health

facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
24b. No. of deliveries in private health
facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
25. No. of non-facility-based deliveries -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
26a. No. of vaginal deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
26b. No. of deliveries by cesarean
section – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
27a. No. of full-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
27b. No. of pre-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B3. Postpartum and Newborn Care
28. No. of postpartum women together
with their newborn who completed at
least 2 postpartum check-ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
 29. No. of postpartum women who
completed iron with folic acid
supplementation - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
30. No. of postpartum women with
Vitamin A supplementation – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
ction C. Child Care and Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)

epB 3 - Total 0 0 0 11. PCV 1 - Total 0 0

0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 12. PCV 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 13. PCV 3 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 14. MMR 1 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
0 0 0 15. MMR 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
1 (November) - Total 0 0 0 20. Td, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
e 1 (November) - Total 0 0 0 21. MR, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

34. Children 12-23 mos. who completed

1 mos. old seen - Total
MNP supplementation - Total
0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
 1 mos. given 1 dose of
35. Children 0-59 mos. seen - Total
100,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos seen - Total 0 0 0 36. Stunted - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos. old given 2
37. Wasted - Total
tamin A 200,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
1 months old who completed
38. Overweight/Obese - Total
lementation - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS

2-23 mos. seen - Total 39. Normal - Total

0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col. 1) (Col 2) (Col 3)

y/o dewormed (2 doses) - 43. Adolescents, 10-19 y/o dewormed

0 0 0 (2 doses) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

ren 12-59 mos. old 50. Diarrhea cases 0-59 mos. received
itamin A - Total 0 0 0 ORS w/ zinc - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old seen 51. Pneumonia cases 0-59 mos. old
0 0 0 seen - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old 52. Pneumonia cases 0-59 mos. old
ORS - Total 0 0 0 completed treatment - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
 To be submitted Quarterly
ous Disease Prevention and Control Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
miasis Prevention and Control E2. Schistosomiasis Prevention and Control (Con't.)
le 5-65 y/o who ingested 7. No. confirmed chronic cases - Total
- Total 0
nts seen - Total 0 8. No. of confirmed cases (acute and
ected cases seen 0 chronic) - Total
clinically diagnosed cases - 9. No. of cases treated - Total
0
rmed acute cases - Total 0 10. No. of confirmed chronic cases
nic clinically diagnosed referred to a hospital facility - Total
al 0
_________________________________________
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
M1
RGY
Total

(Col. 3)

New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
 0 0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0 0
0
0
0 0
0
0
0 0
0
0
 0 0
0
0

Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
 Total
(Col 4)

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Total
(Col 4)
0
0
0
0
0
0

0
0
0
 0
0
0
0
0
0

0
0
0

0
0
0

0
0
0
Total
(Col 4)

0
0
0

0
0
0

0
0
0

0
0
0
 Total
(Col 4)
't.)

Total
(Col 4)
 FHSIS REPORT for the MONTH: ___JANUARY_____
Name of Barangay: _____TAGPAKO_________
Name of BHS: _______________________
Name of Municipality/City: _______________________
Name of Province: ________________________
Projected Population of the Year: _______________________
For submission to RHU/MHC

Section A. Family Planning Services and Dewor

A1. Modern FP Unmet Need Age Total

(Col. 1) (Col. 2) (Col. 3)

10-14 15-19 20-49
1. No. of WRA with unmet
need for modern FP - Total 5 5 5
15
• NHTS 5 5 5 15
• Non-NHTS 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
a. Female Sterilization/ BTL - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
b. Male Sterilization/ NSV-Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
c. Condom - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d. Pills - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
 d.1 Pills-POP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d.2 Pills-COC - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
e. Injectables (DMPA/ POI) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
f. Implant - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g. IUD (IUD-I and IUD-PP) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.1 IUD-I- Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.2 IUD-PP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
h. NFP-LAM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
i. NFP-BBT - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
j. NFP-CMM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
k. NFP-STM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
l. NFP-SDM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
m. Total Current Users 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
Section B. Maternal Care
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
1. No. of pregnant women w/
at least 4 prenatal check-
ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
2. No. of pregnant women
assessed of their nutritional
status during the 1st tri. -Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
c. No. of pregnant women
seen in the first trimester
who have high BMI - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
3. No. of pregnant women for
the first time given 2 doses of
Td vaccination - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
4. No. of pregnant women for
the 2nd or more times given
at least 3 doses of Td
vaccination (Td2 Plus) - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
5. No. of pregnant women who
completed the dose of iron
with folic acid
supplementation - Total 0 0 0 0
 • NHTS 0
• Non-NHTS 0
6. No. of pregnant women who
completed doses of calcium
carbonate supplementation -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
12. No. of pregnant women
tested positive for Hepatitis
B - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
13. No. of pregnant women
screened for HIV - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
14. No. of pregnant women
tested for CBC or Hgb&Hct
count - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
15. No. of pregnant women
tested for CBC or Hgb&Hct
count diagnosed with
anemia - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
16. No. of pregnant women
screened for gestational
diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
17.   No. of pregnant women
tested positive for
gestational diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col 3)  (Col. 4)
 Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
a. No. of deliveries attended
by a doctor - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by a nurse – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
c. No. of deliveries attended
by midwives - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
22. No. of deliveries attended by
non-skilled health
professionals - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
a. No. of deliveries attended
by Hilot/TBA - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by others - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
23. No. of health facility-based
deliveries - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
27c. No. of fetal deaths - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
27d. No. of abortion/
miscarriage - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0

Section C. Child Care a

Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
C1. Immunization Services
1. CPAB - Total 0 0 0 6. DPT-HiB-HepB 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
2. BCG - Total 0 0 0 7. OPV 1 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
3. HepB, within 24 hours. - Total 0 0 0 8. OPV 2 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
4. DPT-HiB-HepB 1 - Total 0 0 0 9. OPV 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
5. DPT-HiB-HepB 2 - Total 0 0 0 10. IPV - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
16. FIC - Total 0 0 0 18. Td, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
17. CIC - Total 0 0 0 19. MR, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
C2. Nutrition Services
22. Newborns initiated on breastfeeding
immediately after birth lasting to 90 mins - 28. Infants 6-11 mos. old seen - Total
Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
23. Preterm/LBW infants given iron 29. Infants 6-11 mos. given 1 dose of
supplementation - Total 0 0 0 Vitamin A 100,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
24. Infants 6 mos. old seen - Total 0 0 0 30. Children 12-59 mos seen - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
25. Infants exclusively breastfed until 6th month - 31. Children 12-59 mos. old given 2
Total 0 0 0 doses of Vitamin A 200,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
26. Infants 6 mos. old initiated to complementary 32. Infant 6-11 months old who completed
feeding with continued breastfeeding - Total 0 0 0 MNP supplementation - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
27. Infants 6 mos. old initiated to complementary
feeding but no longer or never been breastfed 33. Children 12-23 mos. seen - Total
- Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
0
40. 1-19 y/o given 2 doses of deworming drug - 42. SAC, 5-9 y/o dewormed (2 doses) -
Total 0 0 0 Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
41. PSAC, 1-4 y/o dewormed (2 doses) - Total 0 0 0
• NHTS 0
• Non-NHTS 0
0
44. Sick Infants 6-11 mos. old seen - Total 47. Sick Children 12-59 mos. old
0 0 0 received Vitamin A - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
45. Sick Infants 6-11 mos. old received 48. Diarrhea cases 0-59 months old seen
Vitamin A - Total 0 0 0 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
49. Diarrhea cases 0-59 months old
46. Sick Children 12-59 mos. old seen - Total
0 0 0 received ORS - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
 To be submitted Qua
Section E. Infectious Disease Preven
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
E1. Filariasis Prevention and Control E2. Schistosomiasis Prevention and Contro
1. No. of individual examined for lymphatic 1. No. of people 5-65 y/o who ingested
filariasis - Total 0 MDA drugs - Total
2. No. of individual examined found positive for 2. No. of patients seen - Total
lymphatic filariasis - Total 0 3. No. of suspected cases seen
3. No. of lymphatic filariasis cases examined with 4. No. acute clinically diagnosed cases -
manifestation of either lymphedema,hydrocele, Total
elephantiasis - Total
0 5. No. of confirmed acute cases - Total
6. No. of chronic clinically diagnosed
cases - Total
Section F. _________________________
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
 ___JANUARY_____ YEAR: ____2020___

M1
AGPAKO__________________________
_________________________
_________________________

BRGY
________________________
________________________
r submission to RHU/MHC

Services and Deworming for Women of Reproductive Age

Total A3. Deworming Services SES Total

Col. 3) (Col. 1) (Col. 2) (Col. 3)

NHTS Non-NHTS
1. No. of women 20-49 years old given 2 doses of
15 deworming drugs - Total
0 0 0
15
0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
on B. Maternal Care and Services
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

a. Number of pregnant women seen in the

first trimester who have normal BMI -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of pregnant women seen in the first
trimester who have low BMI - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

7. No. of pregnant women given iodine

capsules – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
8. No. of pregnant women given one dose
of deworming tablet - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
9. No. of pregnant women screened for
syphilis - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
10. No. of pregnant women tested positive
for syphilis - Total

0 0 0 0
 • NHTS 0
• Non-NHTS 0
11. No. of pregnant women screened for
Hepatitis B - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
18. No. of deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
19. No. of live births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20a. No. of live births with normal birth
weight - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20b. No. of live births with low birth weight
- Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
20c. No. of live births with unknown birth
weight- Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
21. No. of deliveries attended by skilled
health professionals - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col 3)  (Col. 4)
rks Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

24a. No. of deliveries in public health

facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
24b. No. of deliveries in private health
facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
25. No. of non-facility-based deliveries -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
26a. No. of vaginal deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
26b. No. of deliveries by cesarean
section – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
27a. No. of full-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
27b. No. of pre-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B3. Postpartum and Newborn Care
28. No. of postpartum women together
with their newborn who completed at
least 2 postpartum check-ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
 29. No. of postpartum women who
completed iron with folic acid
supplementation - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
30. No. of postpartum women with
Vitamin A supplementation – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
ction C. Child Care and Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)

epB 3 - Total 0 0 0 11. PCV 1 - Total 0 0

0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 12. PCV 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 13. PCV 3 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 14. MMR 1 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
0 0 0 15. MMR 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
1 (November) - Total 0 0 0 20. Td, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
e 1 (November) - Total 0 0 0 21. MR, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

34. Children 12-23 mos. who completed

1 mos. old seen - Total
MNP supplementation - Total
0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
 1 mos. given 1 dose of
35. Children 0-59 mos. seen - Total
100,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos seen - Total 0 0 0 36. Stunted - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos. old given 2
37. Wasted - Total
tamin A 200,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
1 months old who completed
38. Overweight/Obese - Total
lementation - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS

2-23 mos. seen - Total 39. Normal - Total

0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col. 1) (Col 2) (Col 3)

y/o dewormed (2 doses) - 43. Adolescents, 10-19 y/o dewormed

0 0 0 (2 doses) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

ren 12-59 mos. old 50. Diarrhea cases 0-59 mos. received
itamin A - Total 0 0 0 ORS w/ zinc - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old seen 51. Pneumonia cases 0-59 mos. old
0 0 0 seen - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old 52. Pneumonia cases 0-59 mos. old
ORS - Total 0 0 0 completed treatment - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
 To be submitted Quarterly
ous Disease Prevention and Control Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
miasis Prevention and Control E2. Schistosomiasis Prevention and Control (Con't.)
le 5-65 y/o who ingested 7. No. confirmed chronic cases - Total
- Total 0
nts seen - Total 0 8. No. of confirmed cases (acute and
ected cases seen 0 chronic) - Total
clinically diagnosed cases - 9. No. of cases treated - Total
0
rmed acute cases - Total 0 10. No. of confirmed chronic cases
nic clinically diagnosed referred to a hospital facility - Total
al 0
_________________________________________
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
M1
RGY
Total

(Col. 3)

New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
 0 0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0 0
0
0
0 0
0
0
0 0
0
0
 0 0
0
0

Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
 Total
(Col 4)

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Total
(Col 4)
0
0
0
0
0
0

0
0
0
 0
0
0
0
0
0

0
0
0

0
0
0

0
0
0
Total
(Col 4)

0
0
0

0
0
0

0
0
0

0
0
0
 Total
(Col 4)
't.)

Total
(Col 4)
 FHSIS REPORT for the MONTH: ___JANUARY_____
Name of Barangay: _____TAGPAKO_________
Name of BHS: _______________________
Name of Municipality/City: _______________________
Name of Province: ________________________
Projected Population of the Year: _______________________
For submission to RHU/MHC

Section A. Family Planning Services and Dewor

A1. Modern FP Unmet Need Age Total

(Col. 1) (Col. 2) (Col. 3)

10-14 15-19 20-49
1. No. of WRA with unmet
need for modern FP - Total 5 5 5
15
• NHTS 5 5 5 15
• Non-NHTS 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
a. Female Sterilization/ BTL - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
b. Male Sterilization/ NSV-Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
c. Condom - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d. Pills - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
 d.1 Pills-POP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d.2 Pills-COC - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
e. Injectables (DMPA/ POI) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
f. Implant - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g. IUD (IUD-I and IUD-PP) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.1 IUD-I- Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.2 IUD-PP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
h. NFP-LAM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
i. NFP-BBT - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
j. NFP-CMM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
k. NFP-STM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
l. NFP-SDM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
m. Total Current Users 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
Section B. Maternal Care
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
1. No. of pregnant women w/
at least 4 prenatal check-
ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
2. No. of pregnant women
assessed of their nutritional
status during the 1st tri. -Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
c. No. of pregnant women
seen in the first trimester
who have high BMI - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
3. No. of pregnant women for
the first time given 2 doses of
Td vaccination - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
4. No. of pregnant women for
the 2nd or more times given
at least 3 doses of Td
vaccination (Td2 Plus) - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
5. No. of pregnant women who
completed the dose of iron
with folic acid
supplementation - Total 0 0 0 0
 • NHTS 0
• Non-NHTS 0
6. No. of pregnant women who
completed doses of calcium
carbonate supplementation -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
12. No. of pregnant women
tested positive for Hepatitis
B - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
13. No. of pregnant women
screened for HIV - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
14. No. of pregnant women
tested for CBC or Hgb&Hct
count - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
15. No. of pregnant women
tested for CBC or Hgb&Hct
count diagnosed with
anemia - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
16. No. of pregnant women
screened for gestational
diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
17.   No. of pregnant women
tested positive for
gestational diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col 3)  (Col. 4)
 Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
a. No. of deliveries attended
by a doctor - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by a nurse – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
c. No. of deliveries attended
by midwives - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
22. No. of deliveries attended by
non-skilled health
professionals - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
a. No. of deliveries attended
by Hilot/TBA - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by others - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
23. No. of health facility-based
deliveries - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
27c. No. of fetal deaths - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
27d. No. of abortion/
miscarriage - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0

Section C. Child Care a

Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
C1. Immunization Services
1. CPAB - Total 0 0 0 6. DPT-HiB-HepB 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
2. BCG - Total 0 0 0 7. OPV 1 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
3. HepB, within 24 hours. - Total 0 0 0 8. OPV 2 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
4. DPT-HiB-HepB 1 - Total 0 0 0 9. OPV 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
5. DPT-HiB-HepB 2 - Total 0 0 0 10. IPV - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
16. FIC - Total 0 0 0 18. Td, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
17. CIC - Total 0 0 0 19. MR, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
C2. Nutrition Services
22. Newborns initiated on breastfeeding
immediately after birth lasting to 90 mins - 28. Infants 6-11 mos. old seen - Total
Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
23. Preterm/LBW infants given iron 29. Infants 6-11 mos. given 1 dose of
supplementation - Total 0 0 0 Vitamin A 100,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
24. Infants 6 mos. old seen - Total 0 0 0 30. Children 12-59 mos seen - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
25. Infants exclusively breastfed until 6th month - 31. Children 12-59 mos. old given 2
Total 0 0 0 doses of Vitamin A 200,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
26. Infants 6 mos. old initiated to complementary 32. Infant 6-11 months old who completed
feeding with continued breastfeeding - Total 0 0 0 MNP supplementation - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
27. Infants 6 mos. old initiated to complementary
feeding but no longer or never been breastfed 33. Children 12-23 mos. seen - Total
- Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
0
40. 1-19 y/o given 2 doses of deworming drug - 42. SAC, 5-9 y/o dewormed (2 doses) -
Total 0 0 0 Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
41. PSAC, 1-4 y/o dewormed (2 doses) - Total 0 0 0
• NHTS 0
• Non-NHTS 0
0
44. Sick Infants 6-11 mos. old seen - Total 47. Sick Children 12-59 mos. old
0 0 0 received Vitamin A - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
45. Sick Infants 6-11 mos. old received 48. Diarrhea cases 0-59 months old seen
Vitamin A - Total 0 0 0 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
49. Diarrhea cases 0-59 months old
46. Sick Children 12-59 mos. old seen - Total
0 0 0 received ORS - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
 To be submitted Qua
Section E. Infectious Disease Preven
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
E1. Filariasis Prevention and Control E2. Schistosomiasis Prevention and Contro
1. No. of individual examined for lymphatic 1. No. of people 5-65 y/o who ingested
filariasis - Total 0 MDA drugs - Total
2. No. of individual examined found positive for 2. No. of patients seen - Total
lymphatic filariasis - Total 0 3. No. of suspected cases seen
3. No. of lymphatic filariasis cases examined with 4. No. acute clinically diagnosed cases -
manifestation of either lymphedema,hydrocele, Total
elephantiasis - Total
0 5. No. of confirmed acute cases - Total
6. No. of chronic clinically diagnosed
cases - Total
Section F. _________________________
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
 ___JANUARY_____ YEAR: ____2020___

M1
AGPAKO__________________________
_________________________
_________________________

BRGY
________________________
________________________
r submission to RHU/MHC

Services and Deworming for Women of Reproductive Age

Total A3. Deworming Services SES Total

Col. 3) (Col. 1) (Col. 2) (Col. 3)

NHTS Non-NHTS
1. No. of women 20-49 years old given 2 doses of
15 deworming drugs - Total
0 0 0
15
0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
on B. Maternal Care and Services
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

a. Number of pregnant women seen in the

first trimester who have normal BMI -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of pregnant women seen in the first
trimester who have low BMI - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

7. No. of pregnant women given iodine

capsules – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
8. No. of pregnant women given one dose
of deworming tablet - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
9. No. of pregnant women screened for
syphilis - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
10. No. of pregnant women tested positive
for syphilis - Total

0 0 0 0
 • NHTS 0
• Non-NHTS 0
11. No. of pregnant women screened for
Hepatitis B - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
18. No. of deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
19. No. of live births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20a. No. of live births with normal birth
weight - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20b. No. of live births with low birth weight
- Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
20c. No. of live births with unknown birth
weight- Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
21. No. of deliveries attended by skilled
health professionals - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col 3)  (Col. 4)
rks Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

24a. No. of deliveries in public health

facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
24b. No. of deliveries in private health
facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
25. No. of non-facility-based deliveries -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
26a. No. of vaginal deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
26b. No. of deliveries by cesarean
section – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
27a. No. of full-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
27b. No. of pre-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B3. Postpartum and Newborn Care
28. No. of postpartum women together
with their newborn who completed at
least 2 postpartum check-ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
 29. No. of postpartum women who
completed iron with folic acid
supplementation - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
30. No. of postpartum women with
Vitamin A supplementation – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
ction C. Child Care and Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)

epB 3 - Total 0 0 0 11. PCV 1 - Total 0 0

0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 12. PCV 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 13. PCV 3 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 14. MMR 1 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
0 0 0 15. MMR 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
1 (November) - Total 0 0 0 20. Td, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
e 1 (November) - Total 0 0 0 21. MR, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

34. Children 12-23 mos. who completed

1 mos. old seen - Total
MNP supplementation - Total
0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
 1 mos. given 1 dose of
35. Children 0-59 mos. seen - Total
100,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos seen - Total 0 0 0 36. Stunted - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos. old given 2
37. Wasted - Total
tamin A 200,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
1 months old who completed
38. Overweight/Obese - Total
lementation - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS

2-23 mos. seen - Total 39. Normal - Total

0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col. 1) (Col 2) (Col 3)

y/o dewormed (2 doses) - 43. Adolescents, 10-19 y/o dewormed

0 0 0 (2 doses) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

ren 12-59 mos. old 50. Diarrhea cases 0-59 mos. received
itamin A - Total 0 0 0 ORS w/ zinc - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old seen 51. Pneumonia cases 0-59 mos. old
0 0 0 seen - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old 52. Pneumonia cases 0-59 mos. old
ORS - Total 0 0 0 completed treatment - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
 To be submitted Quarterly
ous Disease Prevention and Control Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
miasis Prevention and Control E2. Schistosomiasis Prevention and Control (Con't.)
le 5-65 y/o who ingested 7. No. confirmed chronic cases - Total
- Total 0
nts seen - Total 0 8. No. of confirmed cases (acute and
ected cases seen 0 chronic) - Total
clinically diagnosed cases - 9. No. of cases treated - Total
0
rmed acute cases - Total 0 10. No. of confirmed chronic cases
nic clinically diagnosed referred to a hospital facility - Total
al 0
_________________________________________
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
M1
RGY
Total

(Col. 3)

New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
 0 0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0 0
0
0
0 0
0
0
0 0
0
0
 0 0
0
0

Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
 Total
(Col 4)

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Total
(Col 4)
0
0
0
0
0
0

0
0
0
 0
0
0
0
0
0

0
0
0

0
0
0

0
0
0
Total
(Col 4)

0
0
0

0
0
0

0
0
0

0
0
0
 Total
(Col 4)
't.)

Total
(Col 4)
 FHSIS REPORT for the MONTH: ___JANUARY_____
Name of Barangay: _____TAGPAKO_________
Name of BHS: _______________________
Name of Municipality/City: _______________________
Name of Province: ________________________
Projected Population of the Year: _______________________
For submission to RHU/MHC

Section A. Family Planning Services and Dewor

A1. Modern FP Unmet Need Age Total

(Col. 1) (Col. 2) (Col. 3)

10-14 15-19 20-49
1. No. of WRA with unmet
need for modern FP - Total 5 5 5
15
• NHTS 5 5 5 15
• Non-NHTS 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
a. Female Sterilization/ BTL - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
b. Male Sterilization/ NSV-Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
c. Condom - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d. Pills - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
 d.1 Pills-POP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d.2 Pills-COC - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
e. Injectables (DMPA/ POI) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
f. Implant - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g. IUD (IUD-I and IUD-PP) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.1 IUD-I- Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.2 IUD-PP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
h. NFP-LAM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
i. NFP-BBT - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
j. NFP-CMM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
k. NFP-STM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
l. NFP-SDM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
m. Total Current Users 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
Section B. Maternal Care
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
1. No. of pregnant women w/
at least 4 prenatal check-
ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
2. No. of pregnant women
assessed of their nutritional
status during the 1st tri. -Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
c. No. of pregnant women
seen in the first trimester
who have high BMI - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
3. No. of pregnant women for
the first time given 2 doses of
Td vaccination - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
4. No. of pregnant women for
the 2nd or more times given
at least 3 doses of Td
vaccination (Td2 Plus) - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
5. No. of pregnant women who
completed the dose of iron
with folic acid
supplementation - Total 0 0 0 0
 • NHTS 0
• Non-NHTS 0
6. No. of pregnant women who
completed doses of calcium
carbonate supplementation -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
12. No. of pregnant women
tested positive for Hepatitis
B - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
13. No. of pregnant women
screened for HIV - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
14. No. of pregnant women
tested for CBC or Hgb&Hct
count - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
15. No. of pregnant women
tested for CBC or Hgb&Hct
count diagnosed with
anemia - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
16. No. of pregnant women
screened for gestational
diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
17.   No. of pregnant women
tested positive for
gestational diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col 3)  (Col. 4)
 Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
a. No. of deliveries attended
by a doctor - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by a nurse – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
c. No. of deliveries attended
by midwives - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
22. No. of deliveries attended by
non-skilled health
professionals - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
a. No. of deliveries attended
by Hilot/TBA - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by others - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
23. No. of health facility-based
deliveries - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
27c. No. of fetal deaths - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
27d. No. of abortion/
miscarriage - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0

Section C. Child Care a

Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
C1. Immunization Services
1. CPAB - Total 0 0 0 6. DPT-HiB-HepB 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
2. BCG - Total 0 0 0 7. OPV 1 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
3. HepB, within 24 hours. - Total 0 0 0 8. OPV 2 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
4. DPT-HiB-HepB 1 - Total 0 0 0 9. OPV 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
5. DPT-HiB-HepB 2 - Total 0 0 0 10. IPV - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
16. FIC - Total 0 0 0 18. Td, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
17. CIC - Total 0 0 0 19. MR, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
C2. Nutrition Services
22. Newborns initiated on breastfeeding
immediately after birth lasting to 90 mins - 28. Infants 6-11 mos. old seen - Total
Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
23. Preterm/LBW infants given iron 29. Infants 6-11 mos. given 1 dose of
supplementation - Total 0 0 0 Vitamin A 100,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
24. Infants 6 mos. old seen - Total 0 0 0 30. Children 12-59 mos seen - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
25. Infants exclusively breastfed until 6th month - 31. Children 12-59 mos. old given 2
Total 0 0 0 doses of Vitamin A 200,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
26. Infants 6 mos. old initiated to complementary 32. Infant 6-11 months old who completed
feeding with continued breastfeeding - Total 0 0 0 MNP supplementation - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
27. Infants 6 mos. old initiated to complementary
feeding but no longer or never been breastfed 33. Children 12-23 mos. seen - Total
- Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
0
40. 1-19 y/o given 2 doses of deworming drug - 42. SAC, 5-9 y/o dewormed (2 doses) -
Total 0 0 0 Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
41. PSAC, 1-4 y/o dewormed (2 doses) - Total 0 0 0
• NHTS 0
• Non-NHTS 0
0
44. Sick Infants 6-11 mos. old seen - Total 47. Sick Children 12-59 mos. old
0 0 0 received Vitamin A - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
45. Sick Infants 6-11 mos. old received 48. Diarrhea cases 0-59 months old seen
Vitamin A - Total 0 0 0 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
49. Diarrhea cases 0-59 months old
46. Sick Children 12-59 mos. old seen - Total
0 0 0 received ORS - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
 To be submitted Qua
Section E. Infectious Disease Preven
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
E1. Filariasis Prevention and Control E2. Schistosomiasis Prevention and Contro
1. No. of individual examined for lymphatic 1. No. of people 5-65 y/o who ingested
filariasis - Total 0 MDA drugs - Total
2. No. of individual examined found positive for 2. No. of patients seen - Total
lymphatic filariasis - Total 0 3. No. of suspected cases seen
3. No. of lymphatic filariasis cases examined with 4. No. acute clinically diagnosed cases -
manifestation of either lymphedema,hydrocele, Total
elephantiasis - Total
0 5. No. of confirmed acute cases - Total
6. No. of chronic clinically diagnosed
cases - Total
Section F. _________________________
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
 ___JANUARY_____ YEAR: ____2020___

M1
AGPAKO__________________________
_________________________
_________________________

BRGY
________________________
________________________
r submission to RHU/MHC

Services and Deworming for Women of Reproductive Age

Total A3. Deworming Services SES Total

Col. 3) (Col. 1) (Col. 2) (Col. 3)

NHTS Non-NHTS
1. No. of women 20-49 years old given 2 doses of
15 deworming drugs - Total
0 0 0
15
0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
on B. Maternal Care and Services
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

a. Number of pregnant women seen in the

first trimester who have normal BMI -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of pregnant women seen in the first
trimester who have low BMI - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

7. No. of pregnant women given iodine

capsules – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
8. No. of pregnant women given one dose
of deworming tablet - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
9. No. of pregnant women screened for
syphilis - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
10. No. of pregnant women tested positive
for syphilis - Total

0 0 0 0
 • NHTS 0
• Non-NHTS 0
11. No. of pregnant women screened for
Hepatitis B - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
18. No. of deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
19. No. of live births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20a. No. of live births with normal birth
weight - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20b. No. of live births with low birth weight
- Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
20c. No. of live births with unknown birth
weight- Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
21. No. of deliveries attended by skilled
health professionals - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col 3)  (Col. 4)
rks Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

24a. No. of deliveries in public health

facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
24b. No. of deliveries in private health
facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
25. No. of non-facility-based deliveries -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
26a. No. of vaginal deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
26b. No. of deliveries by cesarean
section – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
27a. No. of full-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
27b. No. of pre-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B3. Postpartum and Newborn Care
28. No. of postpartum women together
with their newborn who completed at
least 2 postpartum check-ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
 29. No. of postpartum women who
completed iron with folic acid
supplementation - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
30. No. of postpartum women with
Vitamin A supplementation – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
ction C. Child Care and Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)

epB 3 - Total 0 0 0 11. PCV 1 - Total 0 0

0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 12. PCV 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 13. PCV 3 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 14. MMR 1 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
0 0 0 15. MMR 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
1 (November) - Total 0 0 0 20. Td, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
e 1 (November) - Total 0 0 0 21. MR, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

34. Children 12-23 mos. who completed

1 mos. old seen - Total
MNP supplementation - Total
0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
 1 mos. given 1 dose of
35. Children 0-59 mos. seen - Total
100,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos seen - Total 0 0 0 36. Stunted - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos. old given 2
37. Wasted - Total
tamin A 200,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
1 months old who completed
38. Overweight/Obese - Total
lementation - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS

2-23 mos. seen - Total 39. Normal - Total

0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col. 1) (Col 2) (Col 3)

y/o dewormed (2 doses) - 43. Adolescents, 10-19 y/o dewormed

0 0 0 (2 doses) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

ren 12-59 mos. old 50. Diarrhea cases 0-59 mos. received
itamin A - Total 0 0 0 ORS w/ zinc - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old seen 51. Pneumonia cases 0-59 mos. old
0 0 0 seen - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old 52. Pneumonia cases 0-59 mos. old
ORS - Total 0 0 0 completed treatment - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
 To be submitted Quarterly
ous Disease Prevention and Control Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
miasis Prevention and Control E2. Schistosomiasis Prevention and Control (Con't.)
le 5-65 y/o who ingested 7. No. confirmed chronic cases - Total
- Total 0
nts seen - Total 0 8. No. of confirmed cases (acute and
ected cases seen 0 chronic) - Total
clinically diagnosed cases - 9. No. of cases treated - Total
0
rmed acute cases - Total 0 10. No. of confirmed chronic cases
nic clinically diagnosed referred to a hospital facility - Total
al 0
_________________________________________
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
M1
RGY
Total

(Col. 3)

New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
 0 0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0 0
0
0
0 0
0
0
0 0
0
0
 0 0
0
0

Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
 Total
(Col 4)

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Total
(Col 4)
0
0
0
0
0
0

0
0
0
 0
0
0
0
0
0

0
0
0

0
0
0

0
0
0
Total
(Col 4)

0
0
0

0
0
0

0
0
0

0
0
0
 Total
(Col 4)
't.)

Total
(Col 4)
 FHSIS REPORT for the MONTH: ___JANUARY_____
Name of Barangay: _____TAGPAKO_________
Name of BHS: _______________________
Name of Municipality/City: _______________________
Name of Province: ________________________
Projected Population of the Year: _______________________
For submission to RHU/MHC

Section A. Family Planning Services and Dewor

A1. Modern FP Unmet Need Age Total

(Col. 1) (Col. 2) (Col. 3)

10-14 15-19 20-49
1. No. of WRA with unmet
need for modern FP - Total 5 5 5
15
• NHTS 5 5 5 15
• Non-NHTS 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
a. Female Sterilization/ BTL - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
b. Male Sterilization/ NSV-Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
c. Condom - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d. Pills - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
 d.1 Pills-POP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d.2 Pills-COC - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
e. Injectables (DMPA/ POI) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
f. Implant - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g. IUD (IUD-I and IUD-PP) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.1 IUD-I- Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.2 IUD-PP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
h. NFP-LAM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
i. NFP-BBT - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
j. NFP-CMM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
k. NFP-STM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
l. NFP-SDM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
m. Total Current Users 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
Section B. Maternal Care
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
1. No. of pregnant women w/
at least 4 prenatal check-
ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
2. No. of pregnant women
assessed of their nutritional
status during the 1st tri. -Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
c. No. of pregnant women
seen in the first trimester
who have high BMI - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
3. No. of pregnant women for
the first time given 2 doses of
Td vaccination - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
4. No. of pregnant women for
the 2nd or more times given
at least 3 doses of Td
vaccination (Td2 Plus) - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
5. No. of pregnant women who
completed the dose of iron
with folic acid
supplementation - Total 0 0 0 0
 • NHTS 0
• Non-NHTS 0
6. No. of pregnant women who
completed doses of calcium
carbonate supplementation -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
12. No. of pregnant women
tested positive for Hepatitis
B - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
13. No. of pregnant women
screened for HIV - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
14. No. of pregnant women
tested for CBC or Hgb&Hct
count - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
15. No. of pregnant women
tested for CBC or Hgb&Hct
count diagnosed with
anemia - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
16. No. of pregnant women
screened for gestational
diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
17.   No. of pregnant women
tested positive for
gestational diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col 3)  (Col. 4)
 Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
a. No. of deliveries attended
by a doctor - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by a nurse – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
c. No. of deliveries attended
by midwives - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
22. No. of deliveries attended by
non-skilled health
professionals - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
a. No. of deliveries attended
by Hilot/TBA - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by others - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
23. No. of health facility-based
deliveries - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
27c. No. of fetal deaths - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
27d. No. of abortion/
miscarriage - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0

Section C. Child Care a

Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
C1. Immunization Services
1. CPAB - Total 0 0 0 6. DPT-HiB-HepB 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
2. BCG - Total 0 0 0 7. OPV 1 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
3. HepB, within 24 hours. - Total 0 0 0 8. OPV 2 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
4. DPT-HiB-HepB 1 - Total 0 0 0 9. OPV 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
5. DPT-HiB-HepB 2 - Total 0 0 0 10. IPV - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
16. FIC - Total 0 0 0 18. Td, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
17. CIC - Total 0 0 0 19. MR, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
C2. Nutrition Services
22. Newborns initiated on breastfeeding
immediately after birth lasting to 90 mins - 28. Infants 6-11 mos. old seen - Total
Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
23. Preterm/LBW infants given iron 29. Infants 6-11 mos. given 1 dose of
supplementation - Total 0 0 0 Vitamin A 100,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
24. Infants 6 mos. old seen - Total 0 0 0 30. Children 12-59 mos seen - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
25. Infants exclusively breastfed until 6th month - 31. Children 12-59 mos. old given 2
Total 0 0 0 doses of Vitamin A 200,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
26. Infants 6 mos. old initiated to complementary 32. Infant 6-11 months old who completed
feeding with continued breastfeeding - Total 0 0 0 MNP supplementation - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
27. Infants 6 mos. old initiated to complementary
feeding but no longer or never been breastfed 33. Children 12-23 mos. seen - Total
- Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
0
40. 1-19 y/o given 2 doses of deworming drug - 42. SAC, 5-9 y/o dewormed (2 doses) -
Total 0 0 0 Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
41. PSAC, 1-4 y/o dewormed (2 doses) - Total 0 0 0
• NHTS 0
• Non-NHTS 0
0
44. Sick Infants 6-11 mos. old seen - Total 47. Sick Children 12-59 mos. old
0 0 0 received Vitamin A - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
45. Sick Infants 6-11 mos. old received 48. Diarrhea cases 0-59 months old seen
Vitamin A - Total 0 0 0 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
49. Diarrhea cases 0-59 months old
46. Sick Children 12-59 mos. old seen - Total
0 0 0 received ORS - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
 To be submitted Qua
Section E. Infectious Disease Preven
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
E1. Filariasis Prevention and Control E2. Schistosomiasis Prevention and Contro
1. No. of individual examined for lymphatic 1. No. of people 5-65 y/o who ingested
filariasis - Total 0 MDA drugs - Total
2. No. of individual examined found positive for 2. No. of patients seen - Total
lymphatic filariasis - Total 0 3. No. of suspected cases seen
3. No. of lymphatic filariasis cases examined with 4. No. acute clinically diagnosed cases -
manifestation of either lymphedema,hydrocele, Total
elephantiasis - Total
0 5. No. of confirmed acute cases - Total
6. No. of chronic clinically diagnosed
cases - Total
Section F. _________________________
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
 ___JANUARY_____ YEAR: ____2020___

M1
AGPAKO__________________________
_________________________
_________________________

BRGY
________________________
________________________
r submission to RHU/MHC

Services and Deworming for Women of Reproductive Age

Total A3. Deworming Services SES Total

Col. 3) (Col. 1) (Col. 2) (Col. 3)

NHTS Non-NHTS
1. No. of women 20-49 years old given 2 doses of
15 deworming drugs - Total
0 0 0
15
0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
on B. Maternal Care and Services
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

a. Number of pregnant women seen in the

first trimester who have normal BMI -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of pregnant women seen in the first
trimester who have low BMI - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

7. No. of pregnant women given iodine

capsules – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
8. No. of pregnant women given one dose
of deworming tablet - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
9. No. of pregnant women screened for
syphilis - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
10. No. of pregnant women tested positive
for syphilis - Total

0 0 0 0
 • NHTS 0
• Non-NHTS 0
11. No. of pregnant women screened for
Hepatitis B - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
18. No. of deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
19. No. of live births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20a. No. of live births with normal birth
weight - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20b. No. of live births with low birth weight
- Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
20c. No. of live births with unknown birth
weight- Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
21. No. of deliveries attended by skilled
health professionals - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col 3)  (Col. 4)
rks Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

24a. No. of deliveries in public health

facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
24b. No. of deliveries in private health
facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
25. No. of non-facility-based deliveries -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
26a. No. of vaginal deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
26b. No. of deliveries by cesarean
section – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
27a. No. of full-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
27b. No. of pre-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B3. Postpartum and Newborn Care
28. No. of postpartum women together
with their newborn who completed at
least 2 postpartum check-ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
 29. No. of postpartum women who
completed iron with folic acid
supplementation - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
30. No. of postpartum women with
Vitamin A supplementation – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
ction C. Child Care and Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)

epB 3 - Total 0 0 0 11. PCV 1 - Total 0 0

0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 12. PCV 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 13. PCV 3 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 14. MMR 1 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
0 0 0 15. MMR 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
1 (November) - Total 0 0 0 20. Td, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
e 1 (November) - Total 0 0 0 21. MR, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

34. Children 12-23 mos. who completed

1 mos. old seen - Total
MNP supplementation - Total
0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
 1 mos. given 1 dose of
35. Children 0-59 mos. seen - Total
100,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos seen - Total 0 0 0 36. Stunted - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos. old given 2
37. Wasted - Total
tamin A 200,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
1 months old who completed
38. Overweight/Obese - Total
lementation - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS

2-23 mos. seen - Total 39. Normal - Total

0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col. 1) (Col 2) (Col 3)

y/o dewormed (2 doses) - 43. Adolescents, 10-19 y/o dewormed

0 0 0 (2 doses) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

ren 12-59 mos. old 50. Diarrhea cases 0-59 mos. received
itamin A - Total 0 0 0 ORS w/ zinc - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old seen 51. Pneumonia cases 0-59 mos. old
0 0 0 seen - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old 52. Pneumonia cases 0-59 mos. old
ORS - Total 0 0 0 completed treatment - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
 To be submitted Quarterly
ous Disease Prevention and Control Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
miasis Prevention and Control E2. Schistosomiasis Prevention and Control (Con't.)
le 5-65 y/o who ingested 7. No. confirmed chronic cases - Total
- Total 0
nts seen - Total 0 8. No. of confirmed cases (acute and
ected cases seen 0 chronic) - Total
clinically diagnosed cases - 9. No. of cases treated - Total
0
rmed acute cases - Total 0 10. No. of confirmed chronic cases
nic clinically diagnosed referred to a hospital facility - Total
al 0
_________________________________________
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
M1
RGY
Total

(Col. 3)

New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
 0 0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0 0
0
0
0 0
0
0
0 0
0
0
 0 0
0
0

Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
 Total
(Col 4)

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Total
(Col 4)
0
0
0
0
0
0

0
0
0
 0
0
0
0
0
0

0
0
0

0
0
0

0
0
0
Total
(Col 4)

0
0
0

0
0
0

0
0
0

0
0
0
 Total
(Col 4)
't.)

Total
(Col 4)
 FHSIS REPORT for the MONTH: ___JANUARY_____
Name of Barangay: _____TAGPAKO_________
Name of BHS: _______________________
Name of Municipality/City: _______________________
Name of Province: ________________________
Projected Population of the Year: _______________________
For submission to RHU/MHC

Section A. Family Planning Services and Dewor

A1. Modern FP Unmet Need Age Total

(Col. 1) (Col. 2) (Col. 3)

10-14 15-19 20-49
1. No. of WRA with unmet
need for modern FP - Total 5 5 5
15
• NHTS 5 5 5 15
• Non-NHTS 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
a. Female Sterilization/ BTL - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
b. Male Sterilization/ NSV-Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
c. Condom - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d. Pills - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
 d.1 Pills-POP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d.2 Pills-COC - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
e. Injectables (DMPA/ POI) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
f. Implant - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g. IUD (IUD-I and IUD-PP) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.1 IUD-I- Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.2 IUD-PP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
h. NFP-LAM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
i. NFP-BBT - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
j. NFP-CMM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
k. NFP-STM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
l. NFP-SDM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
m. Total Current Users 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
Section B. Maternal Care
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
1. No. of pregnant women w/
at least 4 prenatal check-
ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
2. No. of pregnant women
assessed of their nutritional
status during the 1st tri. -Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
c. No. of pregnant women
seen in the first trimester
who have high BMI - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
3. No. of pregnant women for
the first time given 2 doses of
Td vaccination - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
4. No. of pregnant women for
the 2nd or more times given
at least 3 doses of Td
vaccination (Td2 Plus) - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
5. No. of pregnant women who
completed the dose of iron
with folic acid
supplementation - Total 0 0 0 0
 • NHTS 0
• Non-NHTS 0
6. No. of pregnant women who
completed doses of calcium
carbonate supplementation -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
12. No. of pregnant women
tested positive for Hepatitis
B - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
13. No. of pregnant women
screened for HIV - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
14. No. of pregnant women
tested for CBC or Hgb&Hct
count - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
15. No. of pregnant women
tested for CBC or Hgb&Hct
count diagnosed with
anemia - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
16. No. of pregnant women
screened for gestational
diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
17.   No. of pregnant women
tested positive for
gestational diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col 3)  (Col. 4)
 Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
a. No. of deliveries attended
by a doctor - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by a nurse – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
c. No. of deliveries attended
by midwives - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
22. No. of deliveries attended by
non-skilled health
professionals - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
a. No. of deliveries attended
by Hilot/TBA - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by others - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
23. No. of health facility-based
deliveries - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
27c. No. of fetal deaths - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
27d. No. of abortion/
miscarriage - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0

Section C. Child Care a

Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
C1. Immunization Services
1. CPAB - Total 0 0 0 6. DPT-HiB-HepB 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
2. BCG - Total 0 0 0 7. OPV 1 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
3. HepB, within 24 hours. - Total 0 0 0 8. OPV 2 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
4. DPT-HiB-HepB 1 - Total 0 0 0 9. OPV 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
5. DPT-HiB-HepB 2 - Total 0 0 0 10. IPV - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
16. FIC - Total 0 0 0 18. Td, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
17. CIC - Total 0 0 0 19. MR, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
C2. Nutrition Services
22. Newborns initiated on breastfeeding
immediately after birth lasting to 90 mins - 28. Infants 6-11 mos. old seen - Total
Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
23. Preterm/LBW infants given iron 29. Infants 6-11 mos. given 1 dose of
supplementation - Total 0 0 0 Vitamin A 100,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
24. Infants 6 mos. old seen - Total 0 0 0 30. Children 12-59 mos seen - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
25. Infants exclusively breastfed until 6th month - 31. Children 12-59 mos. old given 2
Total 0 0 0 doses of Vitamin A 200,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
26. Infants 6 mos. old initiated to complementary 32. Infant 6-11 months old who completed
feeding with continued breastfeeding - Total 0 0 0 MNP supplementation - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
27. Infants 6 mos. old initiated to complementary
feeding but no longer or never been breastfed 33. Children 12-23 mos. seen - Total
- Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
0
40. 1-19 y/o given 2 doses of deworming drug - 42. SAC, 5-9 y/o dewormed (2 doses) -
Total 0 0 0 Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
41. PSAC, 1-4 y/o dewormed (2 doses) - Total 0 0 0
• NHTS 0
• Non-NHTS 0
0
44. Sick Infants 6-11 mos. old seen - Total 47. Sick Children 12-59 mos. old
0 0 0 received Vitamin A - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
45. Sick Infants 6-11 mos. old received 48. Diarrhea cases 0-59 months old seen
Vitamin A - Total 0 0 0 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
49. Diarrhea cases 0-59 months old
46. Sick Children 12-59 mos. old seen - Total
0 0 0 received ORS - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
 To be submitted Qua
Section E. Infectious Disease Preven
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
E1. Filariasis Prevention and Control E2. Schistosomiasis Prevention and Contro
1. No. of individual examined for lymphatic 1. No. of people 5-65 y/o who ingested
filariasis - Total 0 MDA drugs - Total
2. No. of individual examined found positive for 2. No. of patients seen - Total
lymphatic filariasis - Total 0 3. No. of suspected cases seen
3. No. of lymphatic filariasis cases examined with 4. No. acute clinically diagnosed cases -
manifestation of either lymphedema,hydrocele, Total
elephantiasis - Total
0 5. No. of confirmed acute cases - Total
6. No. of chronic clinically diagnosed
cases - Total
Section F. _________________________
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
 ___JANUARY_____ YEAR: ____2020___

M1
AGPAKO__________________________
_________________________
_________________________

BRGY
________________________
________________________
r submission to RHU/MHC

Services and Deworming for Women of Reproductive Age

Total A3. Deworming Services SES Total

Col. 3) (Col. 1) (Col. 2) (Col. 3)

NHTS Non-NHTS
1. No. of women 20-49 years old given 2 doses of
15 deworming drugs - Total
0 0 0
15
0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
on B. Maternal Care and Services
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

a. Number of pregnant women seen in the

first trimester who have normal BMI -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of pregnant women seen in the first
trimester who have low BMI - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

7. No. of pregnant women given iodine

capsules – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
8. No. of pregnant women given one dose
of deworming tablet - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
9. No. of pregnant women screened for
syphilis - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
10. No. of pregnant women tested positive
for syphilis - Total

0 0 0 0
 • NHTS 0
• Non-NHTS 0
11. No. of pregnant women screened for
Hepatitis B - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
18. No. of deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
19. No. of live births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20a. No. of live births with normal birth
weight - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20b. No. of live births with low birth weight
- Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
20c. No. of live births with unknown birth
weight- Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
21. No. of deliveries attended by skilled
health professionals - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col 3)  (Col. 4)
rks Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

24a. No. of deliveries in public health

facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
24b. No. of deliveries in private health
facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
25. No. of non-facility-based deliveries -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
26a. No. of vaginal deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
26b. No. of deliveries by cesarean
section – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
27a. No. of full-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
27b. No. of pre-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B3. Postpartum and Newborn Care
28. No. of postpartum women together
with their newborn who completed at
least 2 postpartum check-ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
 29. No. of postpartum women who
completed iron with folic acid
supplementation - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
30. No. of postpartum women with
Vitamin A supplementation – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
ction C. Child Care and Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)

epB 3 - Total 0 0 0 11. PCV 1 - Total 0 0

0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 12. PCV 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 13. PCV 3 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 14. MMR 1 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
0 0 0 15. MMR 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
1 (November) - Total 0 0 0 20. Td, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
e 1 (November) - Total 0 0 0 21. MR, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

34. Children 12-23 mos. who completed

1 mos. old seen - Total
MNP supplementation - Total
0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
 1 mos. given 1 dose of
35. Children 0-59 mos. seen - Total
100,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos seen - Total 0 0 0 36. Stunted - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos. old given 2
37. Wasted - Total
tamin A 200,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
1 months old who completed
38. Overweight/Obese - Total
lementation - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS

2-23 mos. seen - Total 39. Normal - Total

0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col. 1) (Col 2) (Col 3)

y/o dewormed (2 doses) - 43. Adolescents, 10-19 y/o dewormed

0 0 0 (2 doses) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

ren 12-59 mos. old 50. Diarrhea cases 0-59 mos. received
itamin A - Total 0 0 0 ORS w/ zinc - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old seen 51. Pneumonia cases 0-59 mos. old
0 0 0 seen - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old 52. Pneumonia cases 0-59 mos. old
ORS - Total 0 0 0 completed treatment - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
 To be submitted Quarterly
ous Disease Prevention and Control Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
miasis Prevention and Control E2. Schistosomiasis Prevention and Control (Con't.)
le 5-65 y/o who ingested 7. No. confirmed chronic cases - Total
- Total 0
nts seen - Total 0 8. No. of confirmed cases (acute and
ected cases seen 0 chronic) - Total
clinically diagnosed cases - 9. No. of cases treated - Total
0
rmed acute cases - Total 0 10. No. of confirmed chronic cases
nic clinically diagnosed referred to a hospital facility - Total
al 0
_________________________________________
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
M1
RGY
Total

(Col. 3)

New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
 0 0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0 0
0
0
0 0
0
0
0 0
0
0
 0 0
0
0

Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
 Total
(Col 4)

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Total
(Col 4)
0
0
0
0
0
0

0
0
0
 0
0
0
0
0
0

0
0
0

0
0
0

0
0
0
Total
(Col 4)

0
0
0

0
0
0

0
0
0

0
0
0
 Total
(Col 4)
't.)

Total
(Col 4)
 FHSIS REPORT for the MONTH: ___JANUARY_____
Name of Barangay: _____TAGPAKO_________
Name of BHS: _______________________
Name of Municipality/City: _______________________
Name of Province: ________________________
Projected Population of the Year: _______________________
For submission to RHU/MHC

Section A. Family Planning Services and Dewor

A1. Modern FP Unmet Need Age Total

(Col. 1) (Col. 2) (Col. 3)

10-14 15-19 20-49
1. No. of WRA with unmet
need for modern FP - Total 5 5 5
15
• NHTS 5 5 5 15
• Non-NHTS 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
a. Female Sterilization/ BTL - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
b. Male Sterilization/ NSV-Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
c. Condom - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d. Pills - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
 d.1 Pills-POP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d.2 Pills-COC - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
e. Injectables (DMPA/ POI) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
f. Implant - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g. IUD (IUD-I and IUD-PP) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.1 IUD-I- Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.2 IUD-PP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
h. NFP-LAM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
i. NFP-BBT - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
j. NFP-CMM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
k. NFP-STM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
l. NFP-SDM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
m. Total Current Users 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
Section B. Maternal Care
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
1. No. of pregnant women w/
at least 4 prenatal check-
ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
2. No. of pregnant women
assessed of their nutritional
status during the 1st tri. -Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
c. No. of pregnant women
seen in the first trimester
who have high BMI - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
3. No. of pregnant women for
the first time given 2 doses of
Td vaccination - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
4. No. of pregnant women for
the 2nd or more times given
at least 3 doses of Td
vaccination (Td2 Plus) - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
5. No. of pregnant women who
completed the dose of iron
with folic acid
supplementation - Total 0 0 0 0
 • NHTS 0
• Non-NHTS 0
6. No. of pregnant women who
completed doses of calcium
carbonate supplementation -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
12. No. of pregnant women
tested positive for Hepatitis
B - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
13. No. of pregnant women
screened for HIV - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
14. No. of pregnant women
tested for CBC or Hgb&Hct
count - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
15. No. of pregnant women
tested for CBC or Hgb&Hct
count diagnosed with
anemia - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
16. No. of pregnant women
screened for gestational
diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
17.   No. of pregnant women
tested positive for
gestational diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col 3)  (Col. 4)
 Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
a. No. of deliveries attended
by a doctor - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by a nurse – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
c. No. of deliveries attended
by midwives - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
22. No. of deliveries attended by
non-skilled health
professionals - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
a. No. of deliveries attended
by Hilot/TBA - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by others - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
23. No. of health facility-based
deliveries - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
27c. No. of fetal deaths - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
27d. No. of abortion/
miscarriage - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0

Section C. Child Care a

Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
C1. Immunization Services
1. CPAB - Total 0 0 0 6. DPT-HiB-HepB 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
2. BCG - Total 0 0 0 7. OPV 1 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
3. HepB, within 24 hours. - Total 0 0 0 8. OPV 2 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
4. DPT-HiB-HepB 1 - Total 0 0 0 9. OPV 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
5. DPT-HiB-HepB 2 - Total 0 0 0 10. IPV - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
16. FIC - Total 0 0 0 18. Td, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
17. CIC - Total 0 0 0 19. MR, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
C2. Nutrition Services
22. Newborns initiated on breastfeeding
immediately after birth lasting to 90 mins - 28. Infants 6-11 mos. old seen - Total
Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
23. Preterm/LBW infants given iron 29. Infants 6-11 mos. given 1 dose of
supplementation - Total 0 0 0 Vitamin A 100,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
24. Infants 6 mos. old seen - Total 0 0 0 30. Children 12-59 mos seen - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
25. Infants exclusively breastfed until 6th month - 31. Children 12-59 mos. old given 2
Total 0 0 0 doses of Vitamin A 200,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
26. Infants 6 mos. old initiated to complementary 32. Infant 6-11 months old who completed
feeding with continued breastfeeding - Total 0 0 0 MNP supplementation - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
27. Infants 6 mos. old initiated to complementary
feeding but no longer or never been breastfed 33. Children 12-23 mos. seen - Total
- Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
0
40. 1-19 y/o given 2 doses of deworming drug - 42. SAC, 5-9 y/o dewormed (2 doses) -
Total 0 0 0 Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
41. PSAC, 1-4 y/o dewormed (2 doses) - Total 0 0 0
• NHTS 0
• Non-NHTS 0
0
44. Sick Infants 6-11 mos. old seen - Total 47. Sick Children 12-59 mos. old
0 0 0 received Vitamin A - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
45. Sick Infants 6-11 mos. old received 48. Diarrhea cases 0-59 months old seen
Vitamin A - Total 0 0 0 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
49. Diarrhea cases 0-59 months old
46. Sick Children 12-59 mos. old seen - Total
0 0 0 received ORS - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
 To be submitted Qua
Section E. Infectious Disease Preven
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
E1. Filariasis Prevention and Control E2. Schistosomiasis Prevention and Contro
1. No. of individual examined for lymphatic 1. No. of people 5-65 y/o who ingested
filariasis - Total 0 MDA drugs - Total
2. No. of individual examined found positive for 2. No. of patients seen - Total
lymphatic filariasis - Total 0 3. No. of suspected cases seen
3. No. of lymphatic filariasis cases examined with 4. No. acute clinically diagnosed cases -
manifestation of either lymphedema,hydrocele, Total
elephantiasis - Total
0 5. No. of confirmed acute cases - Total
6. No. of chronic clinically diagnosed
cases - Total
Section F. _________________________
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
 ___JANUARY_____ YEAR: ____2020___

M1
AGPAKO__________________________
_________________________
_________________________

BRGY
________________________
________________________
r submission to RHU/MHC

Services and Deworming for Women of Reproductive Age

Total A3. Deworming Services SES Total

Col. 3) (Col. 1) (Col. 2) (Col. 3)

NHTS Non-NHTS
1. No. of women 20-49 years old given 2 doses of
15 deworming drugs - Total
0 0 0
15
0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
on B. Maternal Care and Services
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

a. Number of pregnant women seen in the

first trimester who have normal BMI -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of pregnant women seen in the first
trimester who have low BMI - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

7. No. of pregnant women given iodine

capsules – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
8. No. of pregnant women given one dose
of deworming tablet - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
9. No. of pregnant women screened for
syphilis - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
10. No. of pregnant women tested positive
for syphilis - Total

0 0 0 0
 • NHTS 0
• Non-NHTS 0
11. No. of pregnant women screened for
Hepatitis B - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
18. No. of deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
19. No. of live births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20a. No. of live births with normal birth
weight - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20b. No. of live births with low birth weight
- Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
20c. No. of live births with unknown birth
weight- Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
21. No. of deliveries attended by skilled
health professionals - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col 3)  (Col. 4)
rks Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

24a. No. of deliveries in public health

facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
24b. No. of deliveries in private health
facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
25. No. of non-facility-based deliveries -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
26a. No. of vaginal deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
26b. No. of deliveries by cesarean
section – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
27a. No. of full-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
27b. No. of pre-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B3. Postpartum and Newborn Care
28. No. of postpartum women together
with their newborn who completed at
least 2 postpartum check-ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
 29. No. of postpartum women who
completed iron with folic acid
supplementation - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
30. No. of postpartum women with
Vitamin A supplementation – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
ction C. Child Care and Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)

epB 3 - Total 0 0 0 11. PCV 1 - Total 0 0

0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 12. PCV 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 13. PCV 3 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 14. MMR 1 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
0 0 0 15. MMR 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
1 (November) - Total 0 0 0 20. Td, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
e 1 (November) - Total 0 0 0 21. MR, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

34. Children 12-23 mos. who completed

1 mos. old seen - Total
MNP supplementation - Total
0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
 1 mos. given 1 dose of
35. Children 0-59 mos. seen - Total
100,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos seen - Total 0 0 0 36. Stunted - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos. old given 2
37. Wasted - Total
tamin A 200,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
1 months old who completed
38. Overweight/Obese - Total
lementation - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS

2-23 mos. seen - Total 39. Normal - Total

0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col. 1) (Col 2) (Col 3)

y/o dewormed (2 doses) - 43. Adolescents, 10-19 y/o dewormed

0 0 0 (2 doses) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

ren 12-59 mos. old 50. Diarrhea cases 0-59 mos. received
itamin A - Total 0 0 0 ORS w/ zinc - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old seen 51. Pneumonia cases 0-59 mos. old
0 0 0 seen - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old 52. Pneumonia cases 0-59 mos. old
ORS - Total 0 0 0 completed treatment - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
 To be submitted Quarterly
ous Disease Prevention and Control Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
miasis Prevention and Control E2. Schistosomiasis Prevention and Control (Con't.)
le 5-65 y/o who ingested 7. No. confirmed chronic cases - Total
- Total 0
nts seen - Total 0 8. No. of confirmed cases (acute and
ected cases seen 0 chronic) - Total
clinically diagnosed cases - 9. No. of cases treated - Total
0
rmed acute cases - Total 0 10. No. of confirmed chronic cases
nic clinically diagnosed referred to a hospital facility - Total
al 0
_________________________________________
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
M1
RGY
Total

(Col. 3)

New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
 0 0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0 0
0
0
0 0
0
0
0 0
0
0
 0 0
0
0

Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
 Total
(Col 4)

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Total
(Col 4)
0
0
0
0
0
0

0
0
0
 0
0
0
0
0
0

0
0
0

0
0
0

0
0
0
Total
(Col 4)

0
0
0

0
0
0

0
0
0

0
0
0
 Total
(Col 4)
't.)

Total
(Col 4)
 FHSIS REPORT for the MONTH: ___JANUARY_____
Name of Barangay: _____TAGPAKO_________
Name of BHS: _______________________
Name of Municipality/City: _______________________
Name of Province: ________________________
Projected Population of the Year: _______________________
For submission to RHU/MHC

Section A. Family Planning Services and Dewor

A1. Modern FP Unmet Need Age Total

(Col. 1) (Col. 2) (Col. 3)

10-14 15-19 20-49
1. No. of WRA with unmet
need for modern FP - Total 5 5 5
15
• NHTS 5 5 5 15
• Non-NHTS 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
a. Female Sterilization/ BTL - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
b. Male Sterilization/ NSV-Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
c. Condom - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d. Pills - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
 d.1 Pills-POP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d.2 Pills-COC - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
e. Injectables (DMPA/ POI) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
f. Implant - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g. IUD (IUD-I and IUD-PP) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.1 IUD-I- Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.2 IUD-PP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
h. NFP-LAM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
i. NFP-BBT - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
j. NFP-CMM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
k. NFP-STM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
l. NFP-SDM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
m. Total Current Users 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
Section B. Maternal Care
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
1. No. of pregnant women w/
at least 4 prenatal check-
ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
2. No. of pregnant women
assessed of their nutritional
status during the 1st tri. -Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
c. No. of pregnant women
seen in the first trimester
who have high BMI - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
3. No. of pregnant women for
the first time given 2 doses of
Td vaccination - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
4. No. of pregnant women for
the 2nd or more times given
at least 3 doses of Td
vaccination (Td2 Plus) - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
5. No. of pregnant women who
completed the dose of iron
with folic acid
supplementation - Total 0 0 0 0
 • NHTS 0
• Non-NHTS 0
6. No. of pregnant women who
completed doses of calcium
carbonate supplementation -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
12. No. of pregnant women
tested positive for Hepatitis
B - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
13. No. of pregnant women
screened for HIV - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
14. No. of pregnant women
tested for CBC or Hgb&Hct
count - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
15. No. of pregnant women
tested for CBC or Hgb&Hct
count diagnosed with
anemia - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
16. No. of pregnant women
screened for gestational
diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
17.   No. of pregnant women
tested positive for
gestational diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col 3)  (Col. 4)
 Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
a. No. of deliveries attended
by a doctor - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by a nurse – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
c. No. of deliveries attended
by midwives - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
22. No. of deliveries attended by
non-skilled health
professionals - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
a. No. of deliveries attended
by Hilot/TBA - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by others - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
23. No. of health facility-based
deliveries - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
27c. No. of fetal deaths - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
27d. No. of abortion/
miscarriage - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0

Section C. Child Care a

Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
C1. Immunization Services
1. CPAB - Total 0 0 0 6. DPT-HiB-HepB 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
2. BCG - Total 0 0 0 7. OPV 1 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
3. HepB, within 24 hours. - Total 0 0 0 8. OPV 2 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
4. DPT-HiB-HepB 1 - Total 0 0 0 9. OPV 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
5. DPT-HiB-HepB 2 - Total 0 0 0 10. IPV - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
16. FIC - Total 0 0 0 18. Td, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
17. CIC - Total 0 0 0 19. MR, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
C2. Nutrition Services
22. Newborns initiated on breastfeeding
immediately after birth lasting to 90 mins - 28. Infants 6-11 mos. old seen - Total
Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
23. Preterm/LBW infants given iron 29. Infants 6-11 mos. given 1 dose of
supplementation - Total 0 0 0 Vitamin A 100,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
24. Infants 6 mos. old seen - Total 0 0 0 30. Children 12-59 mos seen - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
25. Infants exclusively breastfed until 6th month - 31. Children 12-59 mos. old given 2
Total 0 0 0 doses of Vitamin A 200,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
26. Infants 6 mos. old initiated to complementary 32. Infant 6-11 months old who completed
feeding with continued breastfeeding - Total 0 0 0 MNP supplementation - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
27. Infants 6 mos. old initiated to complementary
feeding but no longer or never been breastfed 33. Children 12-23 mos. seen - Total
- Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
0
40. 1-19 y/o given 2 doses of deworming drug - 42. SAC, 5-9 y/o dewormed (2 doses) -
Total 0 0 0 Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
41. PSAC, 1-4 y/o dewormed (2 doses) - Total 0 0 0
• NHTS 0
• Non-NHTS 0
0
44. Sick Infants 6-11 mos. old seen - Total 47. Sick Children 12-59 mos. old
0 0 0 received Vitamin A - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
45. Sick Infants 6-11 mos. old received 48. Diarrhea cases 0-59 months old seen
Vitamin A - Total 0 0 0 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
49. Diarrhea cases 0-59 months old
46. Sick Children 12-59 mos. old seen - Total
0 0 0 received ORS - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
 To be submitted Qua
Section E. Infectious Disease Preven
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
E1. Filariasis Prevention and Control E2. Schistosomiasis Prevention and Contro
1. No. of individual examined for lymphatic 1. No. of people 5-65 y/o who ingested
filariasis - Total 0 MDA drugs - Total
2. No. of individual examined found positive for 2. No. of patients seen - Total
lymphatic filariasis - Total 0 3. No. of suspected cases seen
3. No. of lymphatic filariasis cases examined with 4. No. acute clinically diagnosed cases -
manifestation of either lymphedema,hydrocele, Total
elephantiasis - Total
0 5. No. of confirmed acute cases - Total
6. No. of chronic clinically diagnosed
cases - Total
Section F. _________________________
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
 ___JANUARY_____ YEAR: ____2020___

M1
AGPAKO__________________________
_________________________
_________________________

BRGY
________________________
________________________
r submission to RHU/MHC

Services and Deworming for Women of Reproductive Age

Total A3. Deworming Services SES Total

Col. 3) (Col. 1) (Col. 2) (Col. 3)

NHTS Non-NHTS
1. No. of women 20-49 years old given 2 doses of
15 deworming drugs - Total
0 0 0
15
0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
on B. Maternal Care and Services
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

a. Number of pregnant women seen in the

first trimester who have normal BMI -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of pregnant women seen in the first
trimester who have low BMI - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

7. No. of pregnant women given iodine

capsules – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
8. No. of pregnant women given one dose
of deworming tablet - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
9. No. of pregnant women screened for
syphilis - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
10. No. of pregnant women tested positive
for syphilis - Total

0 0 0 0
 • NHTS 0
• Non-NHTS 0
11. No. of pregnant women screened for
Hepatitis B - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
18. No. of deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
19. No. of live births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20a. No. of live births with normal birth
weight - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20b. No. of live births with low birth weight
- Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
20c. No. of live births with unknown birth
weight- Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
21. No. of deliveries attended by skilled
health professionals - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col 3)  (Col. 4)
rks Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

24a. No. of deliveries in public health

facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
24b. No. of deliveries in private health
facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
25. No. of non-facility-based deliveries -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
26a. No. of vaginal deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
26b. No. of deliveries by cesarean
section – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
27a. No. of full-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
27b. No. of pre-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B3. Postpartum and Newborn Care
28. No. of postpartum women together
with their newborn who completed at
least 2 postpartum check-ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
 29. No. of postpartum women who
completed iron with folic acid
supplementation - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
30. No. of postpartum women with
Vitamin A supplementation – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
ction C. Child Care and Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)

epB 3 - Total 0 0 0 11. PCV 1 - Total 0 0

0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 12. PCV 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 13. PCV 3 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 14. MMR 1 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
0 0 0 15. MMR 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
1 (November) - Total 0 0 0 20. Td, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
e 1 (November) - Total 0 0 0 21. MR, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

34. Children 12-23 mos. who completed

1 mos. old seen - Total
MNP supplementation - Total
0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
 1 mos. given 1 dose of
35. Children 0-59 mos. seen - Total
100,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos seen - Total 0 0 0 36. Stunted - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos. old given 2
37. Wasted - Total
tamin A 200,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
1 months old who completed
38. Overweight/Obese - Total
lementation - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS

2-23 mos. seen - Total 39. Normal - Total

0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col. 1) (Col 2) (Col 3)

y/o dewormed (2 doses) - 43. Adolescents, 10-19 y/o dewormed

0 0 0 (2 doses) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

ren 12-59 mos. old 50. Diarrhea cases 0-59 mos. received
itamin A - Total 0 0 0 ORS w/ zinc - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old seen 51. Pneumonia cases 0-59 mos. old
0 0 0 seen - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old 52. Pneumonia cases 0-59 mos. old
ORS - Total 0 0 0 completed treatment - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
 To be submitted Quarterly
ous Disease Prevention and Control Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
miasis Prevention and Control E2. Schistosomiasis Prevention and Control (Con't.)
le 5-65 y/o who ingested 7. No. confirmed chronic cases - Total
- Total 0
nts seen - Total 0 8. No. of confirmed cases (acute and
ected cases seen 0 chronic) - Total
clinically diagnosed cases - 9. No. of cases treated - Total
0
rmed acute cases - Total 0 10. No. of confirmed chronic cases
nic clinically diagnosed referred to a hospital facility - Total
al 0
_________________________________________
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
M1
RGY
Total

(Col. 3)

New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
 0 0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0 0
0
0
0 0
0
0
0 0
0
0
 0 0
0
0

Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
 Total
(Col 4)

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Total
(Col 4)
0
0
0
0
0
0

0
0
0
 0
0
0
0
0
0

0
0
0

0
0
0

0
0
0
Total
(Col 4)

0
0
0

0
0
0

0
0
0

0
0
0
 Total
(Col 4)
't.)

Total
(Col 4)
 FHSIS REPORT for the MONTH: ___JANUARY_____
Name of Barangay: _____TAGPAKO_________
Name of BHS: _______________________
Name of Municipality/City: _______________________
Name of Province: ________________________
Projected Population of the Year: _______________________
For submission to RHU/MHC

Section A. Family Planning Services and Dewor

A1. Modern FP Unmet Need Age Total

(Col. 1) (Col. 2) (Col. 3)

10-14 15-19 20-49
1. No. of WRA with unmet
need for modern FP - Total 5 5 5
15
• NHTS 5 5 5 15
• Non-NHTS 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
a. Female Sterilization/ BTL - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
b. Male Sterilization/ NSV-Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
c. Condom - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d. Pills - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
 d.1 Pills-POP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d.2 Pills-COC - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
e. Injectables (DMPA/ POI) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
f. Implant - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g. IUD (IUD-I and IUD-PP) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.1 IUD-I- Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.2 IUD-PP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
h. NFP-LAM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
i. NFP-BBT - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
j. NFP-CMM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
k. NFP-STM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
l. NFP-SDM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
m. Total Current Users 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
Section B. Maternal Care
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
1. No. of pregnant women w/
at least 4 prenatal check-
ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
2. No. of pregnant women
assessed of their nutritional
status during the 1st tri. -Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
c. No. of pregnant women
seen in the first trimester
who have high BMI - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
3. No. of pregnant women for
the first time given 2 doses of
Td vaccination - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
4. No. of pregnant women for
the 2nd or more times given
at least 3 doses of Td
vaccination (Td2 Plus) - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
5. No. of pregnant women who
completed the dose of iron
with folic acid
supplementation - Total 0 0 0 0
 • NHTS 0
• Non-NHTS 0
6. No. of pregnant women who
completed doses of calcium
carbonate supplementation -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
12. No. of pregnant women
tested positive for Hepatitis
B - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
13. No. of pregnant women
screened for HIV - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
14. No. of pregnant women
tested for CBC or Hgb&Hct
count - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
15. No. of pregnant women
tested for CBC or Hgb&Hct
count diagnosed with
anemia - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
16. No. of pregnant women
screened for gestational
diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
17.   No. of pregnant women
tested positive for
gestational diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col 3)  (Col. 4)
 Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
a. No. of deliveries attended
by a doctor - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by a nurse – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
c. No. of deliveries attended
by midwives - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
22. No. of deliveries attended by
non-skilled health
professionals - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
a. No. of deliveries attended
by Hilot/TBA - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by others - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
23. No. of health facility-based
deliveries - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
27c. No. of fetal deaths - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
27d. No. of abortion/
miscarriage - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0

Section C. Child Care a

Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
C1. Immunization Services
1. CPAB - Total 0 0 0 6. DPT-HiB-HepB 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
2. BCG - Total 0 0 0 7. OPV 1 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
3. HepB, within 24 hours. - Total 0 0 0 8. OPV 2 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
4. DPT-HiB-HepB 1 - Total 0 0 0 9. OPV 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
5. DPT-HiB-HepB 2 - Total 0 0 0 10. IPV - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
16. FIC - Total 0 0 0 18. Td, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
17. CIC - Total 0 0 0 19. MR, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
C2. Nutrition Services
22. Newborns initiated on breastfeeding
immediately after birth lasting to 90 mins - 28. Infants 6-11 mos. old seen - Total
Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
23. Preterm/LBW infants given iron 29. Infants 6-11 mos. given 1 dose of
supplementation - Total 0 0 0 Vitamin A 100,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
24. Infants 6 mos. old seen - Total 0 0 0 30. Children 12-59 mos seen - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
25. Infants exclusively breastfed until 6th month - 31. Children 12-59 mos. old given 2
Total 0 0 0 doses of Vitamin A 200,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
26. Infants 6 mos. old initiated to complementary 32. Infant 6-11 months old who completed
feeding with continued breastfeeding - Total 0 0 0 MNP supplementation - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
27. Infants 6 mos. old initiated to complementary
feeding but no longer or never been breastfed 33. Children 12-23 mos. seen - Total
- Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
0
40. 1-19 y/o given 2 doses of deworming drug - 42. SAC, 5-9 y/o dewormed (2 doses) -
Total 0 0 0 Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
41. PSAC, 1-4 y/o dewormed (2 doses) - Total 0 0 0
• NHTS 0
• Non-NHTS 0
0
44. Sick Infants 6-11 mos. old seen - Total 47. Sick Children 12-59 mos. old
0 0 0 received Vitamin A - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
45. Sick Infants 6-11 mos. old received 48. Diarrhea cases 0-59 months old seen
Vitamin A - Total 0 0 0 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
49. Diarrhea cases 0-59 months old
46. Sick Children 12-59 mos. old seen - Total
0 0 0 received ORS - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
 To be submitted Qua
Section E. Infectious Disease Preven
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
E1. Filariasis Prevention and Control E2. Schistosomiasis Prevention and Contro
1. No. of individual examined for lymphatic 1. No. of people 5-65 y/o who ingested
filariasis - Total 0 MDA drugs - Total
2. No. of individual examined found positive for 2. No. of patients seen - Total
lymphatic filariasis - Total 0 3. No. of suspected cases seen
3. No. of lymphatic filariasis cases examined with 4. No. acute clinically diagnosed cases -
manifestation of either lymphedema,hydrocele, Total
elephantiasis - Total
0 5. No. of confirmed acute cases - Total
6. No. of chronic clinically diagnosed
cases - Total
Section F. _________________________
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
 ___JANUARY_____ YEAR: ____2020___

M1
AGPAKO__________________________
_________________________
_________________________

BRGY
________________________
________________________
r submission to RHU/MHC

Services and Deworming for Women of Reproductive Age

Total A3. Deworming Services SES Total

Col. 3) (Col. 1) (Col. 2) (Col. 3)

NHTS Non-NHTS
1. No. of women 20-49 years old given 2 doses of
15 deworming drugs - Total
0 0 0
15
0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
on B. Maternal Care and Services
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

a. Number of pregnant women seen in the

first trimester who have normal BMI -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of pregnant women seen in the first
trimester who have low BMI - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

7. No. of pregnant women given iodine

capsules – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
8. No. of pregnant women given one dose
of deworming tablet - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
9. No. of pregnant women screened for
syphilis - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
10. No. of pregnant women tested positive
for syphilis - Total

0 0 0 0
 • NHTS 0
• Non-NHTS 0
11. No. of pregnant women screened for
Hepatitis B - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
18. No. of deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
19. No. of live births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20a. No. of live births with normal birth
weight - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20b. No. of live births with low birth weight
- Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
20c. No. of live births with unknown birth
weight- Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
21. No. of deliveries attended by skilled
health professionals - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col 3)  (Col. 4)
rks Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

24a. No. of deliveries in public health

facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
24b. No. of deliveries in private health
facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
25. No. of non-facility-based deliveries -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
26a. No. of vaginal deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
26b. No. of deliveries by cesarean
section – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
27a. No. of full-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
27b. No. of pre-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B3. Postpartum and Newborn Care
28. No. of postpartum women together
with their newborn who completed at
least 2 postpartum check-ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
 29. No. of postpartum women who
completed iron with folic acid
supplementation - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
30. No. of postpartum women with
Vitamin A supplementation – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
ction C. Child Care and Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)

epB 3 - Total 0 0 0 11. PCV 1 - Total 0 0

0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 12. PCV 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 13. PCV 3 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 14. MMR 1 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
0 0 0 15. MMR 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
1 (November) - Total 0 0 0 20. Td, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
e 1 (November) - Total 0 0 0 21. MR, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

34. Children 12-23 mos. who completed

1 mos. old seen - Total
MNP supplementation - Total
0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
 1 mos. given 1 dose of
35. Children 0-59 mos. seen - Total
100,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos seen - Total 0 0 0 36. Stunted - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos. old given 2
37. Wasted - Total
tamin A 200,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
1 months old who completed
38. Overweight/Obese - Total
lementation - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS

2-23 mos. seen - Total 39. Normal - Total

0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col. 1) (Col 2) (Col 3)

y/o dewormed (2 doses) - 43. Adolescents, 10-19 y/o dewormed

0 0 0 (2 doses) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

ren 12-59 mos. old 50. Diarrhea cases 0-59 mos. received
itamin A - Total 0 0 0 ORS w/ zinc - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old seen 51. Pneumonia cases 0-59 mos. old
0 0 0 seen - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old 52. Pneumonia cases 0-59 mos. old
ORS - Total 0 0 0 completed treatment - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
 To be submitted Quarterly
ous Disease Prevention and Control Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
miasis Prevention and Control E2. Schistosomiasis Prevention and Control (Con't.)
le 5-65 y/o who ingested 7. No. confirmed chronic cases - Total
- Total 0
nts seen - Total 0 8. No. of confirmed cases (acute and
ected cases seen 0 chronic) - Total
clinically diagnosed cases - 9. No. of cases treated - Total
0
rmed acute cases - Total 0 10. No. of confirmed chronic cases
nic clinically diagnosed referred to a hospital facility - Total
al 0
_________________________________________
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
M1
RGY
Total

(Col. 3)

New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
 0 0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0 0
0
0
0 0
0
0
0 0
0
0
 0 0
0
0

Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
 Total
(Col 4)

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Total
(Col 4)
0
0
0
0
0
0

0
0
0
 0
0
0
0
0
0

0
0
0

0
0
0

0
0
0
Total
(Col 4)

0
0
0

0
0
0

0
0
0

0
0
0
 Total
(Col 4)
't.)

Total
(Col 4)
 FHSIS REPORT for the MONTH: ___JANUARY_____
Name of Barangay: _____TAGPAKO_________
Name of BHS: _______________________
Name of Municipality/City: _______________________
Name of Province: ________________________
Projected Population of the Year: _______________________
For submission to RHU/MHC

Section A. Family Planning Services and Dewor

A1. Modern FP Unmet Need Age Total

(Col. 1) (Col. 2) (Col. 3)

10-14 15-19 20-49
1. No. of WRA with unmet
need for modern FP - Total 5 5 5
15
• NHTS 5 5 5 15
• Non-NHTS 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
a. Female Sterilization/ BTL - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
b. Male Sterilization/ NSV-Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
c. Condom - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d. Pills - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
 d.1 Pills-POP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d.2 Pills-COC - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
e. Injectables (DMPA/ POI) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
f. Implant - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g. IUD (IUD-I and IUD-PP) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.1 IUD-I- Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.2 IUD-PP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
h. NFP-LAM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
i. NFP-BBT - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
j. NFP-CMM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
k. NFP-STM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
l. NFP-SDM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
m. Total Current Users 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
Section B. Maternal Care
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
1. No. of pregnant women w/
at least 4 prenatal check-
ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
2. No. of pregnant women
assessed of their nutritional
status during the 1st tri. -Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
c. No. of pregnant women
seen in the first trimester
who have high BMI - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
3. No. of pregnant women for
the first time given 2 doses of
Td vaccination - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
4. No. of pregnant women for
the 2nd or more times given
at least 3 doses of Td
vaccination (Td2 Plus) - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
5. No. of pregnant women who
completed the dose of iron
with folic acid
supplementation - Total 0 0 0 0
 • NHTS 0
• Non-NHTS 0
6. No. of pregnant women who
completed doses of calcium
carbonate supplementation -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
12. No. of pregnant women
tested positive for Hepatitis
B - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
13. No. of pregnant women
screened for HIV - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
14. No. of pregnant women
tested for CBC or Hgb&Hct
count - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
15. No. of pregnant women
tested for CBC or Hgb&Hct
count diagnosed with
anemia - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
16. No. of pregnant women
screened for gestational
diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
17.   No. of pregnant women
tested positive for
gestational diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col 3)  (Col. 4)
 Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
a. No. of deliveries attended
by a doctor - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by a nurse – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
c. No. of deliveries attended
by midwives - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
22. No. of deliveries attended by
non-skilled health
professionals - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
a. No. of deliveries attended
by Hilot/TBA - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by others - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
23. No. of health facility-based
deliveries - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
27c. No. of fetal deaths - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
27d. No. of abortion/
miscarriage - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0

Section C. Child Care a

Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
C1. Immunization Services
1. CPAB - Total 0 0 0 6. DPT-HiB-HepB 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
2. BCG - Total 0 0 0 7. OPV 1 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
3. HepB, within 24 hours. - Total 0 0 0 8. OPV 2 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
4. DPT-HiB-HepB 1 - Total 0 0 0 9. OPV 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
5. DPT-HiB-HepB 2 - Total 0 0 0 10. IPV - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
16. FIC - Total 0 0 0 18. Td, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
17. CIC - Total 0 0 0 19. MR, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
C2. Nutrition Services
22. Newborns initiated on breastfeeding
immediately after birth lasting to 90 mins - 28. Infants 6-11 mos. old seen - Total
Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
23. Preterm/LBW infants given iron 29. Infants 6-11 mos. given 1 dose of
supplementation - Total 0 0 0 Vitamin A 100,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
24. Infants 6 mos. old seen - Total 0 0 0 30. Children 12-59 mos seen - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
25. Infants exclusively breastfed until 6th month - 31. Children 12-59 mos. old given 2
Total 0 0 0 doses of Vitamin A 200,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
26. Infants 6 mos. old initiated to complementary 32. Infant 6-11 months old who completed
feeding with continued breastfeeding - Total 0 0 0 MNP supplementation - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
27. Infants 6 mos. old initiated to complementary
feeding but no longer or never been breastfed 33. Children 12-23 mos. seen - Total
- Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
0
40. 1-19 y/o given 2 doses of deworming drug - 42. SAC, 5-9 y/o dewormed (2 doses) -
Total 0 0 0 Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
41. PSAC, 1-4 y/o dewormed (2 doses) - Total 0 0 0
• NHTS 0
• Non-NHTS 0
0
44. Sick Infants 6-11 mos. old seen - Total 47. Sick Children 12-59 mos. old
0 0 0 received Vitamin A - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
45. Sick Infants 6-11 mos. old received 48. Diarrhea cases 0-59 months old seen
Vitamin A - Total 0 0 0 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
49. Diarrhea cases 0-59 months old
46. Sick Children 12-59 mos. old seen - Total
0 0 0 received ORS - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
 To be submitted Qua
Section E. Infectious Disease Preven
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
E1. Filariasis Prevention and Control E2. Schistosomiasis Prevention and Contro
1. No. of individual examined for lymphatic 1. No. of people 5-65 y/o who ingested
filariasis - Total 0 MDA drugs - Total
2. No. of individual examined found positive for 2. No. of patients seen - Total
lymphatic filariasis - Total 0 3. No. of suspected cases seen
3. No. of lymphatic filariasis cases examined with 4. No. acute clinically diagnosed cases -
manifestation of either lymphedema,hydrocele, Total
elephantiasis - Total
0 5. No. of confirmed acute cases - Total
6. No. of chronic clinically diagnosed
cases - Total
Section F. _________________________
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
 ___JANUARY_____ YEAR: ____2020___

M1
AGPAKO__________________________
_________________________
_________________________

BRGY
________________________
________________________
r submission to RHU/MHC

Services and Deworming for Women of Reproductive Age

Total A3. Deworming Services SES Total

Col. 3) (Col. 1) (Col. 2) (Col. 3)

NHTS Non-NHTS
1. No. of women 20-49 years old given 2 doses of
15 deworming drugs - Total
0 0 0
15
0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
on B. Maternal Care and Services
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

a. Number of pregnant women seen in the

first trimester who have normal BMI -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of pregnant women seen in the first
trimester who have low BMI - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

7. No. of pregnant women given iodine

capsules – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
8. No. of pregnant women given one dose
of deworming tablet - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
9. No. of pregnant women screened for
syphilis - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
10. No. of pregnant women tested positive
for syphilis - Total

0 0 0 0
 • NHTS 0
• Non-NHTS 0
11. No. of pregnant women screened for
Hepatitis B - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
18. No. of deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
19. No. of live births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20a. No. of live births with normal birth
weight - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20b. No. of live births with low birth weight
- Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
20c. No. of live births with unknown birth
weight- Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
21. No. of deliveries attended by skilled
health professionals - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col 3)  (Col. 4)
rks Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

24a. No. of deliveries in public health

facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
24b. No. of deliveries in private health
facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
25. No. of non-facility-based deliveries -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
26a. No. of vaginal deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
26b. No. of deliveries by cesarean
section – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
27a. No. of full-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
27b. No. of pre-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B3. Postpartum and Newborn Care
28. No. of postpartum women together
with their newborn who completed at
least 2 postpartum check-ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
 29. No. of postpartum women who
completed iron with folic acid
supplementation - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
30. No. of postpartum women with
Vitamin A supplementation – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
ction C. Child Care and Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)

epB 3 - Total 0 0 0 11. PCV 1 - Total 0 0

0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 12. PCV 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 13. PCV 3 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 14. MMR 1 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
0 0 0 15. MMR 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
1 (November) - Total 0 0 0 20. Td, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
e 1 (November) - Total 0 0 0 21. MR, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

34. Children 12-23 mos. who completed

1 mos. old seen - Total
MNP supplementation - Total
0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
 1 mos. given 1 dose of
35. Children 0-59 mos. seen - Total
100,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos seen - Total 0 0 0 36. Stunted - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos. old given 2
37. Wasted - Total
tamin A 200,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
1 months old who completed
38. Overweight/Obese - Total
lementation - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS

2-23 mos. seen - Total 39. Normal - Total

0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col. 1) (Col 2) (Col 3)

y/o dewormed (2 doses) - 43. Adolescents, 10-19 y/o dewormed

0 0 0 (2 doses) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

ren 12-59 mos. old 50. Diarrhea cases 0-59 mos. received
itamin A - Total 0 0 0 ORS w/ zinc - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old seen 51. Pneumonia cases 0-59 mos. old
0 0 0 seen - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old 52. Pneumonia cases 0-59 mos. old
ORS - Total 0 0 0 completed treatment - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
 To be submitted Quarterly
ous Disease Prevention and Control Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
miasis Prevention and Control E2. Schistosomiasis Prevention and Control (Con't.)
le 5-65 y/o who ingested 7. No. confirmed chronic cases - Total
- Total 0
nts seen - Total 0 8. No. of confirmed cases (acute and
ected cases seen 0 chronic) - Total
clinically diagnosed cases - 9. No. of cases treated - Total
0
rmed acute cases - Total 0 10. No. of confirmed chronic cases
nic clinically diagnosed referred to a hospital facility - Total
al 0
_________________________________________
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
M1
RGY
Total

(Col. 3)

New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
 0 0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0 0
0
0
0 0
0
0
0 0
0
0
 0 0
0
0

Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
 Total
(Col 4)

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Total
(Col 4)
0
0
0
0
0
0

0
0
0
 0
0
0
0
0
0

0
0
0

0
0
0

0
0
0
Total
(Col 4)

0
0
0

0
0
0

0
0
0

0
0
0
 Total
(Col 4)
't.)

Total
(Col 4)
 FHSIS REPORT for the MONTH: ___JANUARY_____
Name of Barangay: _____TAGPAKO_________
Name of BHS: _______________________
Name of Municipality/City: _______________________
Name of Province: ________________________
Projected Population of the Year: _______________________
For submission to RHU/MHC

Section A. Family Planning Services and Dewor

A1. Modern FP Unmet Need Age Total

(Col. 1) (Col. 2) (Col. 3)

10-14 15-19 20-49
1. No. of WRA with unmet
need for modern FP - Total 5 5 5
15
• NHTS 5 5 5 15
• Non-NHTS 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
a. Female Sterilization/ BTL - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
b. Male Sterilization/ NSV-Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
c. Condom - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d. Pills - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
 d.1 Pills-POP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d.2 Pills-COC - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
e. Injectables (DMPA/ POI) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
f. Implant - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g. IUD (IUD-I and IUD-PP) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.1 IUD-I- Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.2 IUD-PP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
h. NFP-LAM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
i. NFP-BBT - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
j. NFP-CMM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
k. NFP-STM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
l. NFP-SDM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
m. Total Current Users 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
Section B. Maternal Care
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
1. No. of pregnant women w/
at least 4 prenatal check-
ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
2. No. of pregnant women
assessed of their nutritional
status during the 1st tri. -Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
c. No. of pregnant women
seen in the first trimester
who have high BMI - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
3. No. of pregnant women for
the first time given 2 doses of
Td vaccination - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
4. No. of pregnant women for
the 2nd or more times given
at least 3 doses of Td
vaccination (Td2 Plus) - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
5. No. of pregnant women who
completed the dose of iron
with folic acid
supplementation - Total 0 0 0 0
 • NHTS 0
• Non-NHTS 0
6. No. of pregnant women who
completed doses of calcium
carbonate supplementation -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
12. No. of pregnant women
tested positive for Hepatitis
B - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
13. No. of pregnant women
screened for HIV - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
14. No. of pregnant women
tested for CBC or Hgb&Hct
count - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
15. No. of pregnant women
tested for CBC or Hgb&Hct
count diagnosed with
anemia - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
16. No. of pregnant women
screened for gestational
diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
17.   No. of pregnant women
tested positive for
gestational diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col 3)  (Col. 4)
 Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
a. No. of deliveries attended
by a doctor - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by a nurse – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
c. No. of deliveries attended
by midwives - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
22. No. of deliveries attended by
non-skilled health
professionals - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
a. No. of deliveries attended
by Hilot/TBA - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by others - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
23. No. of health facility-based
deliveries - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
27c. No. of fetal deaths - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
27d. No. of abortion/
miscarriage - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0

Section C. Child Care a

Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
C1. Immunization Services
1. CPAB - Total 0 0 0 6. DPT-HiB-HepB 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
2. BCG - Total 0 0 0 7. OPV 1 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
3. HepB, within 24 hours. - Total 0 0 0 8. OPV 2 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
4. DPT-HiB-HepB 1 - Total 0 0 0 9. OPV 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
5. DPT-HiB-HepB 2 - Total 0 0 0 10. IPV - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
16. FIC - Total 0 0 0 18. Td, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
17. CIC - Total 0 0 0 19. MR, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
C2. Nutrition Services
22. Newborns initiated on breastfeeding
immediately after birth lasting to 90 mins - 28. Infants 6-11 mos. old seen - Total
Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
23. Preterm/LBW infants given iron 29. Infants 6-11 mos. given 1 dose of
supplementation - Total 0 0 0 Vitamin A 100,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
24. Infants 6 mos. old seen - Total 0 0 0 30. Children 12-59 mos seen - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
25. Infants exclusively breastfed until 6th month - 31. Children 12-59 mos. old given 2
Total 0 0 0 doses of Vitamin A 200,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
26. Infants 6 mos. old initiated to complementary 32. Infant 6-11 months old who completed
feeding with continued breastfeeding - Total 0 0 0 MNP supplementation - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
27. Infants 6 mos. old initiated to complementary
feeding but no longer or never been breastfed 33. Children 12-23 mos. seen - Total
- Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
0
40. 1-19 y/o given 2 doses of deworming drug - 42. SAC, 5-9 y/o dewormed (2 doses) -
Total 0 0 0 Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
41. PSAC, 1-4 y/o dewormed (2 doses) - Total 0 0 0
• NHTS 0
• Non-NHTS 0
0
44. Sick Infants 6-11 mos. old seen - Total 47. Sick Children 12-59 mos. old
0 0 0 received Vitamin A - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
45. Sick Infants 6-11 mos. old received 48. Diarrhea cases 0-59 months old seen
Vitamin A - Total 0 0 0 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
49. Diarrhea cases 0-59 months old
46. Sick Children 12-59 mos. old seen - Total
0 0 0 received ORS - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
 To be submitted Qua
Section E. Infectious Disease Preven
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
E1. Filariasis Prevention and Control E2. Schistosomiasis Prevention and Contro
1. No. of individual examined for lymphatic 1. No. of people 5-65 y/o who ingested
filariasis - Total 0 MDA drugs - Total
2. No. of individual examined found positive for 2. No. of patients seen - Total
lymphatic filariasis - Total 0 3. No. of suspected cases seen
3. No. of lymphatic filariasis cases examined with 4. No. acute clinically diagnosed cases -
manifestation of either lymphedema,hydrocele, Total
elephantiasis - Total
0 5. No. of confirmed acute cases - Total
6. No. of chronic clinically diagnosed
cases - Total
Section F. _________________________
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
 ___JANUARY_____ YEAR: ____2020___

M1
AGPAKO__________________________
_________________________
_________________________

BRGY
________________________
________________________
r submission to RHU/MHC

Services and Deworming for Women of Reproductive Age

Total A3. Deworming Services SES Total

Col. 3) (Col. 1) (Col. 2) (Col. 3)

NHTS Non-NHTS
1. No. of women 20-49 years old given 2 doses of
15 deworming drugs - Total
0 0 0
15
0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
on B. Maternal Care and Services
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

a. Number of pregnant women seen in the

first trimester who have normal BMI -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of pregnant women seen in the first
trimester who have low BMI - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

7. No. of pregnant women given iodine

capsules – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
8. No. of pregnant women given one dose
of deworming tablet - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
9. No. of pregnant women screened for
syphilis - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
10. No. of pregnant women tested positive
for syphilis - Total

0 0 0 0
 • NHTS 0
• Non-NHTS 0
11. No. of pregnant women screened for
Hepatitis B - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
18. No. of deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
19. No. of live births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20a. No. of live births with normal birth
weight - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20b. No. of live births with low birth weight
- Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
20c. No. of live births with unknown birth
weight- Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
21. No. of deliveries attended by skilled
health professionals - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col 3)  (Col. 4)
rks Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

24a. No. of deliveries in public health

facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
24b. No. of deliveries in private health
facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
25. No. of non-facility-based deliveries -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
26a. No. of vaginal deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
26b. No. of deliveries by cesarean
section – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
27a. No. of full-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
27b. No. of pre-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B3. Postpartum and Newborn Care
28. No. of postpartum women together
with their newborn who completed at
least 2 postpartum check-ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
 29. No. of postpartum women who
completed iron with folic acid
supplementation - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
30. No. of postpartum women with
Vitamin A supplementation – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
ction C. Child Care and Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)

epB 3 - Total 0 0 0 11. PCV 1 - Total 0 0

0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 12. PCV 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 13. PCV 3 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 14. MMR 1 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
0 0 0 15. MMR 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
1 (November) - Total 0 0 0 20. Td, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
e 1 (November) - Total 0 0 0 21. MR, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

34. Children 12-23 mos. who completed

1 mos. old seen - Total
MNP supplementation - Total
0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
 1 mos. given 1 dose of
35. Children 0-59 mos. seen - Total
100,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos seen - Total 0 0 0 36. Stunted - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos. old given 2
37. Wasted - Total
tamin A 200,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
1 months old who completed
38. Overweight/Obese - Total
lementation - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS

2-23 mos. seen - Total 39. Normal - Total

0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col. 1) (Col 2) (Col 3)

y/o dewormed (2 doses) - 43. Adolescents, 10-19 y/o dewormed

0 0 0 (2 doses) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

ren 12-59 mos. old 50. Diarrhea cases 0-59 mos. received
itamin A - Total 0 0 0 ORS w/ zinc - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old seen 51. Pneumonia cases 0-59 mos. old
0 0 0 seen - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old 52. Pneumonia cases 0-59 mos. old
ORS - Total 0 0 0 completed treatment - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
 To be submitted Quarterly
ous Disease Prevention and Control Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
miasis Prevention and Control E2. Schistosomiasis Prevention and Control (Con't.)
le 5-65 y/o who ingested 7. No. confirmed chronic cases - Total
- Total 0
nts seen - Total 0 8. No. of confirmed cases (acute and
ected cases seen 0 chronic) - Total
clinically diagnosed cases - 9. No. of cases treated - Total
0
rmed acute cases - Total 0 10. No. of confirmed chronic cases
nic clinically diagnosed referred to a hospital facility - Total
al 0
_________________________________________
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
M1
RGY
Total

(Col. 3)

New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
 0 0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0 0
0
0
0 0
0
0
0 0
0
0
 0 0
0
0

Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
 Total
(Col 4)

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Total
(Col 4)
0
0
0
0
0
0

0
0
0
 0
0
0
0
0
0

0
0
0

0
0
0

0
0
0
Total
(Col 4)

0
0
0

0
0
0

0
0
0

0
0
0
 Total
(Col 4)
't.)

Total
(Col 4)
 FHSIS REPORT for the MONTH: ___JANUARY_____
Name of Barangay: _____TAGPAKO_________
Name of BHS: _______________________
Name of Municipality/City: _______________________
Name of Province: ________________________
Projected Population of the Year: _______________________
For submission to RHU/MHC

Section A. Family Planning Services and Dewor

A1. Modern FP Unmet Need Age Total

(Col. 1) (Col. 2) (Col. 3)

10-14 15-19 20-49
1. No. of WRA with unmet
need for modern FP - Total 5 5 5
15
• NHTS 5 5 5 15
• Non-NHTS 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
a. Female Sterilization/ BTL - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
b. Male Sterilization/ NSV-Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
c. Condom - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d. Pills - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
 d.1 Pills-POP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d.2 Pills-COC - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
e. Injectables (DMPA/ POI) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
f. Implant - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g. IUD (IUD-I and IUD-PP) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.1 IUD-I- Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.2 IUD-PP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
h. NFP-LAM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
i. NFP-BBT - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
j. NFP-CMM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
k. NFP-STM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
l. NFP-SDM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
m. Total Current Users 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
Section B. Maternal Care
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
1. No. of pregnant women w/
at least 4 prenatal check-
ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
2. No. of pregnant women
assessed of their nutritional
status during the 1st tri. -Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
c. No. of pregnant women
seen in the first trimester
who have high BMI - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
3. No. of pregnant women for
the first time given 2 doses of
Td vaccination - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
4. No. of pregnant women for
the 2nd or more times given
at least 3 doses of Td
vaccination (Td2 Plus) - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
5. No. of pregnant women who
completed the dose of iron
with folic acid
supplementation - Total 0 0 0 0
 • NHTS 0
• Non-NHTS 0
6. No. of pregnant women who
completed doses of calcium
carbonate supplementation -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
12. No. of pregnant women
tested positive for Hepatitis
B - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
13. No. of pregnant women
screened for HIV - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
14. No. of pregnant women
tested for CBC or Hgb&Hct
count - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
15. No. of pregnant women
tested for CBC or Hgb&Hct
count diagnosed with
anemia - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
16. No. of pregnant women
screened for gestational
diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
17.   No. of pregnant women
tested positive for
gestational diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col 3)  (Col. 4)
 Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
a. No. of deliveries attended
by a doctor - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by a nurse – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
c. No. of deliveries attended
by midwives - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
22. No. of deliveries attended by
non-skilled health
professionals - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
a. No. of deliveries attended
by Hilot/TBA - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by others - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
23. No. of health facility-based
deliveries - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
27c. No. of fetal deaths - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
27d. No. of abortion/
miscarriage - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0

Section C. Child Care a

Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
C1. Immunization Services
1. CPAB - Total 0 0 0 6. DPT-HiB-HepB 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
2. BCG - Total 0 0 0 7. OPV 1 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
3. HepB, within 24 hours. - Total 0 0 0 8. OPV 2 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
4. DPT-HiB-HepB 1 - Total 0 0 0 9. OPV 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
5. DPT-HiB-HepB 2 - Total 0 0 0 10. IPV - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
16. FIC - Total 0 0 0 18. Td, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
17. CIC - Total 0 0 0 19. MR, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
C2. Nutrition Services
22. Newborns initiated on breastfeeding
immediately after birth lasting to 90 mins - 28. Infants 6-11 mos. old seen - Total
Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
23. Preterm/LBW infants given iron 29. Infants 6-11 mos. given 1 dose of
supplementation - Total 0 0 0 Vitamin A 100,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
24. Infants 6 mos. old seen - Total 0 0 0 30. Children 12-59 mos seen - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
25. Infants exclusively breastfed until 6th month - 31. Children 12-59 mos. old given 2
Total 0 0 0 doses of Vitamin A 200,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
26. Infants 6 mos. old initiated to complementary 32. Infant 6-11 months old who completed
feeding with continued breastfeeding - Total 0 0 0 MNP supplementation - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
27. Infants 6 mos. old initiated to complementary
feeding but no longer or never been breastfed 33. Children 12-23 mos. seen - Total
- Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
0
40. 1-19 y/o given 2 doses of deworming drug - 42. SAC, 5-9 y/o dewormed (2 doses) -
Total 0 0 0 Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
41. PSAC, 1-4 y/o dewormed (2 doses) - Total 0 0 0
• NHTS 0
• Non-NHTS 0
0
44. Sick Infants 6-11 mos. old seen - Total 47. Sick Children 12-59 mos. old
0 0 0 received Vitamin A - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
45. Sick Infants 6-11 mos. old received 48. Diarrhea cases 0-59 months old seen
Vitamin A - Total 0 0 0 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
49. Diarrhea cases 0-59 months old
46. Sick Children 12-59 mos. old seen - Total
0 0 0 received ORS - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
 To be submitted Qua
Section E. Infectious Disease Preven
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
E1. Filariasis Prevention and Control E2. Schistosomiasis Prevention and Contro
1. No. of individual examined for lymphatic 1. No. of people 5-65 y/o who ingested
filariasis - Total 0 MDA drugs - Total
2. No. of individual examined found positive for 2. No. of patients seen - Total
lymphatic filariasis - Total 0 3. No. of suspected cases seen
3. No. of lymphatic filariasis cases examined with 4. No. acute clinically diagnosed cases -
manifestation of either lymphedema,hydrocele, Total
elephantiasis - Total
0 5. No. of confirmed acute cases - Total
6. No. of chronic clinically diagnosed
cases - Total
Section F. _________________________
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
 ___JANUARY_____ YEAR: ____2020___

M1
AGPAKO__________________________
_________________________
_________________________

BRGY
________________________
________________________
r submission to RHU/MHC

Services and Deworming for Women of Reproductive Age

Total A3. Deworming Services SES Total

Col. 3) (Col. 1) (Col. 2) (Col. 3)

NHTS Non-NHTS
1. No. of women 20-49 years old given 2 doses of
15 deworming drugs - Total
0 0 0
15
0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
on B. Maternal Care and Services
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

a. Number of pregnant women seen in the

first trimester who have normal BMI -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of pregnant women seen in the first
trimester who have low BMI - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

7. No. of pregnant women given iodine

capsules – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
8. No. of pregnant women given one dose
of deworming tablet - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
9. No. of pregnant women screened for
syphilis - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
10. No. of pregnant women tested positive
for syphilis - Total

0 0 0 0
 • NHTS 0
• Non-NHTS 0
11. No. of pregnant women screened for
Hepatitis B - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
18. No. of deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
19. No. of live births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20a. No. of live births with normal birth
weight - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20b. No. of live births with low birth weight
- Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
20c. No. of live births with unknown birth
weight- Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
21. No. of deliveries attended by skilled
health professionals - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col 3)  (Col. 4)
rks Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

24a. No. of deliveries in public health

facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
24b. No. of deliveries in private health
facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
25. No. of non-facility-based deliveries -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
26a. No. of vaginal deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
26b. No. of deliveries by cesarean
section – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
27a. No. of full-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
27b. No. of pre-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B3. Postpartum and Newborn Care
28. No. of postpartum women together
with their newborn who completed at
least 2 postpartum check-ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
 29. No. of postpartum women who
completed iron with folic acid
supplementation - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
30. No. of postpartum women with
Vitamin A supplementation – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
ction C. Child Care and Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)

epB 3 - Total 0 0 0 11. PCV 1 - Total 0 0

0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 12. PCV 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 13. PCV 3 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 14. MMR 1 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
0 0 0 15. MMR 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
1 (November) - Total 0 0 0 20. Td, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
e 1 (November) - Total 0 0 0 21. MR, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

34. Children 12-23 mos. who completed

1 mos. old seen - Total
MNP supplementation - Total
0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
 1 mos. given 1 dose of
35. Children 0-59 mos. seen - Total
100,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos seen - Total 0 0 0 36. Stunted - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos. old given 2
37. Wasted - Total
tamin A 200,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
1 months old who completed
38. Overweight/Obese - Total
lementation - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS

2-23 mos. seen - Total 39. Normal - Total

0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col. 1) (Col 2) (Col 3)

y/o dewormed (2 doses) - 43. Adolescents, 10-19 y/o dewormed

0 0 0 (2 doses) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

ren 12-59 mos. old 50. Diarrhea cases 0-59 mos. received
itamin A - Total 0 0 0 ORS w/ zinc - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old seen 51. Pneumonia cases 0-59 mos. old
0 0 0 seen - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old 52. Pneumonia cases 0-59 mos. old
ORS - Total 0 0 0 completed treatment - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
 To be submitted Quarterly
ous Disease Prevention and Control Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
miasis Prevention and Control E2. Schistosomiasis Prevention and Control (Con't.)
le 5-65 y/o who ingested 7. No. confirmed chronic cases - Total
- Total 0
nts seen - Total 0 8. No. of confirmed cases (acute and
ected cases seen 0 chronic) - Total
clinically diagnosed cases - 9. No. of cases treated - Total
0
rmed acute cases - Total 0 10. No. of confirmed chronic cases
nic clinically diagnosed referred to a hospital facility - Total
al 0
_________________________________________
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
M1
RGY
Total

(Col. 3)

New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
 0 0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0 0
0
0
0 0
0
0
0 0
0
0
 0 0
0
0

Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
 Total
(Col 4)

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Total
(Col 4)
0
0
0
0
0
0

0
0
0
 0
0
0
0
0
0

0
0
0

0
0
0

0
0
0
Total
(Col 4)

0
0
0

0
0
0

0
0
0

0
0
0
 Total
(Col 4)
't.)

Total
(Col 4)
 FHSIS REPORT for the MONTH: ___JANUARY_____
Name of Barangay: _____TAGPAKO_________
Name of BHS: _______________________
Name of Municipality/City: _______________________
Name of Province: ________________________
Projected Population of the Year: _______________________
For submission to RHU/MHC

Section A. Family Planning Services and Dewor

A1. Modern FP Unmet Need Age Total

(Col. 1) (Col. 2) (Col. 3)

10-14 15-19 20-49
1. No. of WRA with unmet
need for modern FP - Total 5 5 5
15
• NHTS 5 5 5 15
• Non-NHTS 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
a. Female Sterilization/ BTL - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
b. Male Sterilization/ NSV-Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
c. Condom - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d. Pills - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
 d.1 Pills-POP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d.2 Pills-COC - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
e. Injectables (DMPA/ POI) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
f. Implant - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g. IUD (IUD-I and IUD-PP) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.1 IUD-I- Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.2 IUD-PP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
h. NFP-LAM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
i. NFP-BBT - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
j. NFP-CMM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
k. NFP-STM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
l. NFP-SDM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
m. Total Current Users 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
Section B. Maternal Care
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
1. No. of pregnant women w/
at least 4 prenatal check-
ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
2. No. of pregnant women
assessed of their nutritional
status during the 1st tri. -Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
c. No. of pregnant women
seen in the first trimester
who have high BMI - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
3. No. of pregnant women for
the first time given 2 doses of
Td vaccination - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
4. No. of pregnant women for
the 2nd or more times given
at least 3 doses of Td
vaccination (Td2 Plus) - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
5. No. of pregnant women who
completed the dose of iron
with folic acid
supplementation - Total 0 0 0 0
 • NHTS 0
• Non-NHTS 0
6. No. of pregnant women who
completed doses of calcium
carbonate supplementation -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
12. No. of pregnant women
tested positive for Hepatitis
B - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
13. No. of pregnant women
screened for HIV - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
14. No. of pregnant women
tested for CBC or Hgb&Hct
count - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
15. No. of pregnant women
tested for CBC or Hgb&Hct
count diagnosed with
anemia - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
16. No. of pregnant women
screened for gestational
diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
17.   No. of pregnant women
tested positive for
gestational diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col 3)  (Col. 4)
 Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
a. No. of deliveries attended
by a doctor - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by a nurse – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
c. No. of deliveries attended
by midwives - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
22. No. of deliveries attended by
non-skilled health
professionals - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
a. No. of deliveries attended
by Hilot/TBA - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by others - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
23. No. of health facility-based
deliveries - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
27c. No. of fetal deaths - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
27d. No. of abortion/
miscarriage - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0

Section C. Child Care a

Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
C1. Immunization Services
1. CPAB - Total 0 0 0 6. DPT-HiB-HepB 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
2. BCG - Total 0 0 0 7. OPV 1 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
3. HepB, within 24 hours. - Total 0 0 0 8. OPV 2 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
4. DPT-HiB-HepB 1 - Total 0 0 0 9. OPV 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
5. DPT-HiB-HepB 2 - Total 0 0 0 10. IPV - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
16. FIC - Total 0 0 0 18. Td, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
17. CIC - Total 0 0 0 19. MR, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
C2. Nutrition Services
22. Newborns initiated on breastfeeding
immediately after birth lasting to 90 mins - 28. Infants 6-11 mos. old seen - Total
Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
23. Preterm/LBW infants given iron 29. Infants 6-11 mos. given 1 dose of
supplementation - Total 0 0 0 Vitamin A 100,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
24. Infants 6 mos. old seen - Total 0 0 0 30. Children 12-59 mos seen - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
25. Infants exclusively breastfed until 6th month - 31. Children 12-59 mos. old given 2
Total 0 0 0 doses of Vitamin A 200,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
26. Infants 6 mos. old initiated to complementary 32. Infant 6-11 months old who completed
feeding with continued breastfeeding - Total 0 0 0 MNP supplementation - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
27. Infants 6 mos. old initiated to complementary
feeding but no longer or never been breastfed 33. Children 12-23 mos. seen - Total
- Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
0
40. 1-19 y/o given 2 doses of deworming drug - 42. SAC, 5-9 y/o dewormed (2 doses) -
Total 0 0 0 Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
41. PSAC, 1-4 y/o dewormed (2 doses) - Total 0 0 0
• NHTS 0
• Non-NHTS 0
0
44. Sick Infants 6-11 mos. old seen - Total 47. Sick Children 12-59 mos. old
0 0 0 received Vitamin A - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
45. Sick Infants 6-11 mos. old received 48. Diarrhea cases 0-59 months old seen
Vitamin A - Total 0 0 0 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
49. Diarrhea cases 0-59 months old
46. Sick Children 12-59 mos. old seen - Total
0 0 0 received ORS - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
 To be submitted Qua
Section E. Infectious Disease Preven
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
E1. Filariasis Prevention and Control E2. Schistosomiasis Prevention and Contro
1. No. of individual examined for lymphatic 1. No. of people 5-65 y/o who ingested
filariasis - Total 0 MDA drugs - Total
2. No. of individual examined found positive for 2. No. of patients seen - Total
lymphatic filariasis - Total 0 3. No. of suspected cases seen
3. No. of lymphatic filariasis cases examined with 4. No. acute clinically diagnosed cases -
manifestation of either lymphedema,hydrocele, Total
elephantiasis - Total
0 5. No. of confirmed acute cases - Total
6. No. of chronic clinically diagnosed
cases - Total
Section F. _________________________
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
 ___JANUARY_____ YEAR: ____2020___

M1
AGPAKO__________________________
_________________________
_________________________

BRGY
________________________
________________________
r submission to RHU/MHC

Services and Deworming for Women of Reproductive Age

Total A3. Deworming Services SES Total

Col. 3) (Col. 1) (Col. 2) (Col. 3)

NHTS Non-NHTS
1. No. of women 20-49 years old given 2 doses of
15 deworming drugs - Total
0 0 0
15
0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
on B. Maternal Care and Services
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

a. Number of pregnant women seen in the

first trimester who have normal BMI -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of pregnant women seen in the first
trimester who have low BMI - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

7. No. of pregnant women given iodine

capsules – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
8. No. of pregnant women given one dose
of deworming tablet - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
9. No. of pregnant women screened for
syphilis - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
10. No. of pregnant women tested positive
for syphilis - Total

0 0 0 0
 • NHTS 0
• Non-NHTS 0
11. No. of pregnant women screened for
Hepatitis B - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
18. No. of deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
19. No. of live births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20a. No. of live births with normal birth
weight - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20b. No. of live births with low birth weight
- Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
20c. No. of live births with unknown birth
weight- Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
21. No. of deliveries attended by skilled
health professionals - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col 3)  (Col. 4)
rks Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

24a. No. of deliveries in public health

facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
24b. No. of deliveries in private health
facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
25. No. of non-facility-based deliveries -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
26a. No. of vaginal deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
26b. No. of deliveries by cesarean
section – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
27a. No. of full-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
27b. No. of pre-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B3. Postpartum and Newborn Care
28. No. of postpartum women together
with their newborn who completed at
least 2 postpartum check-ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
 29. No. of postpartum women who
completed iron with folic acid
supplementation - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
30. No. of postpartum women with
Vitamin A supplementation – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
ction C. Child Care and Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)

epB 3 - Total 0 0 0 11. PCV 1 - Total 0 0

0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 12. PCV 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 13. PCV 3 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 14. MMR 1 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
0 0 0 15. MMR 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
1 (November) - Total 0 0 0 20. Td, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
e 1 (November) - Total 0 0 0 21. MR, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

34. Children 12-23 mos. who completed

1 mos. old seen - Total
MNP supplementation - Total
0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
 1 mos. given 1 dose of
35. Children 0-59 mos. seen - Total
100,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos seen - Total 0 0 0 36. Stunted - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos. old given 2
37. Wasted - Total
tamin A 200,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
1 months old who completed
38. Overweight/Obese - Total
lementation - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS

2-23 mos. seen - Total 39. Normal - Total

0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col. 1) (Col 2) (Col 3)

y/o dewormed (2 doses) - 43. Adolescents, 10-19 y/o dewormed

0 0 0 (2 doses) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

ren 12-59 mos. old 50. Diarrhea cases 0-59 mos. received
itamin A - Total 0 0 0 ORS w/ zinc - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old seen 51. Pneumonia cases 0-59 mos. old
0 0 0 seen - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old 52. Pneumonia cases 0-59 mos. old
ORS - Total 0 0 0 completed treatment - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
 To be submitted Quarterly
ous Disease Prevention and Control Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
miasis Prevention and Control E2. Schistosomiasis Prevention and Control (Con't.)
le 5-65 y/o who ingested 7. No. confirmed chronic cases - Total
- Total 0
nts seen - Total 0 8. No. of confirmed cases (acute and
ected cases seen 0 chronic) - Total
clinically diagnosed cases - 9. No. of cases treated - Total
0
rmed acute cases - Total 0 10. No. of confirmed chronic cases
nic clinically diagnosed referred to a hospital facility - Total
al 0
_________________________________________
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
M1
RGY
Total

(Col. 3)

New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
 0 0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0 0
0
0
0 0
0
0
0 0
0
0
 0 0
0
0

Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
 Total
(Col 4)

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Total
(Col 4)
0
0
0
0
0
0

0
0
0
 0
0
0
0
0
0

0
0
0

0
0
0

0
0
0
Total
(Col 4)

0
0
0

0
0
0

0
0
0

0
0
0
 Total
(Col 4)
't.)

Total
(Col 4)
 FHSIS REPORT for the MONTH: ___JANUARY_____
Name of Barangay: _____TAGPAKO_________
Name of BHS: _______________________
Name of Municipality/City: _______________________
Name of Province: ________________________
Projected Population of the Year: _______________________
For submission to RHU/MHC

Section A. Family Planning Services and Dewor

A1. Modern FP Unmet Need Age Total

(Col. 1) (Col. 2) (Col. 3)

10-14 15-19 20-49
1. No. of WRA with unmet
need for modern FP - Total 5 5 5
15
• NHTS 5 5 5 15
• Non-NHTS 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
a. Female Sterilization/ BTL - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
b. Male Sterilization/ NSV-Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
c. Condom - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d. Pills - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
 d.1 Pills-POP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d.2 Pills-COC - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
e. Injectables (DMPA/ POI) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
f. Implant - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g. IUD (IUD-I and IUD-PP) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.1 IUD-I- Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.2 IUD-PP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
h. NFP-LAM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
i. NFP-BBT - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
j. NFP-CMM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
k. NFP-STM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
l. NFP-SDM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
m. Total Current Users 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
Section B. Maternal Care
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
1. No. of pregnant women w/
at least 4 prenatal check-
ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
2. No. of pregnant women
assessed of their nutritional
status during the 1st tri. -Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
c. No. of pregnant women
seen in the first trimester
who have high BMI - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
3. No. of pregnant women for
the first time given 2 doses of
Td vaccination - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
4. No. of pregnant women for
the 2nd or more times given
at least 3 doses of Td
vaccination (Td2 Plus) - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
5. No. of pregnant women who
completed the dose of iron
with folic acid
supplementation - Total 0 0 0 0
 • NHTS 0
• Non-NHTS 0
6. No. of pregnant women who
completed doses of calcium
carbonate supplementation -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
12. No. of pregnant women
tested positive for Hepatitis
B - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
13. No. of pregnant women
screened for HIV - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
14. No. of pregnant women
tested for CBC or Hgb&Hct
count - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
15. No. of pregnant women
tested for CBC or Hgb&Hct
count diagnosed with
anemia - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
16. No. of pregnant women
screened for gestational
diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
17.   No. of pregnant women
tested positive for
gestational diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col 3)  (Col. 4)
 Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
a. No. of deliveries attended
by a doctor - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by a nurse – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
c. No. of deliveries attended
by midwives - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
22. No. of deliveries attended by
non-skilled health
professionals - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
a. No. of deliveries attended
by Hilot/TBA - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by others - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
23. No. of health facility-based
deliveries - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
27c. No. of fetal deaths - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
27d. No. of abortion/
miscarriage - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0

Section C. Child Care a

Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
C1. Immunization Services
1. CPAB - Total 0 0 0 6. DPT-HiB-HepB 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
2. BCG - Total 0 0 0 7. OPV 1 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
3. HepB, within 24 hours. - Total 0 0 0 8. OPV 2 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
4. DPT-HiB-HepB 1 - Total 0 0 0 9. OPV 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
5. DPT-HiB-HepB 2 - Total 0 0 0 10. IPV - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
16. FIC - Total 0 0 0 18. Td, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
17. CIC - Total 0 0 0 19. MR, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
C2. Nutrition Services
22. Newborns initiated on breastfeeding
immediately after birth lasting to 90 mins - 28. Infants 6-11 mos. old seen - Total
Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
23. Preterm/LBW infants given iron 29. Infants 6-11 mos. given 1 dose of
supplementation - Total 0 0 0 Vitamin A 100,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
24. Infants 6 mos. old seen - Total 0 0 0 30. Children 12-59 mos seen - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
25. Infants exclusively breastfed until 6th month - 31. Children 12-59 mos. old given 2
Total 0 0 0 doses of Vitamin A 200,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
26. Infants 6 mos. old initiated to complementary 32. Infant 6-11 months old who completed
feeding with continued breastfeeding - Total 0 0 0 MNP supplementation - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
27. Infants 6 mos. old initiated to complementary
feeding but no longer or never been breastfed 33. Children 12-23 mos. seen - Total
- Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
0
40. 1-19 y/o given 2 doses of deworming drug - 42. SAC, 5-9 y/o dewormed (2 doses) -
Total 0 0 0 Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
41. PSAC, 1-4 y/o dewormed (2 doses) - Total 0 0 0
• NHTS 0
• Non-NHTS 0
0
44. Sick Infants 6-11 mos. old seen - Total 47. Sick Children 12-59 mos. old
0 0 0 received Vitamin A - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
45. Sick Infants 6-11 mos. old received 48. Diarrhea cases 0-59 months old seen
Vitamin A - Total 0 0 0 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
49. Diarrhea cases 0-59 months old
46. Sick Children 12-59 mos. old seen - Total
0 0 0 received ORS - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
 To be submitted Qua
Section E. Infectious Disease Preven
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
E1. Filariasis Prevention and Control E2. Schistosomiasis Prevention and Contro
1. No. of individual examined for lymphatic 1. No. of people 5-65 y/o who ingested
filariasis - Total 0 MDA drugs - Total
2. No. of individual examined found positive for 2. No. of patients seen - Total
lymphatic filariasis - Total 0 3. No. of suspected cases seen
3. No. of lymphatic filariasis cases examined with 4. No. acute clinically diagnosed cases -
manifestation of either lymphedema,hydrocele, Total
elephantiasis - Total
0 5. No. of confirmed acute cases - Total
6. No. of chronic clinically diagnosed
cases - Total
Section F. _________________________
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
 ___JANUARY_____ YEAR: ____2020___

M1
AGPAKO__________________________
_________________________
_________________________

BRGY
________________________
________________________
r submission to RHU/MHC

Services and Deworming for Women of Reproductive Age

Total A3. Deworming Services SES Total

Col. 3) (Col. 1) (Col. 2) (Col. 3)

NHTS Non-NHTS
1. No. of women 20-49 years old given 2 doses of
15 deworming drugs - Total
0 0 0
15
0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
on B. Maternal Care and Services
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

a. Number of pregnant women seen in the

first trimester who have normal BMI -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of pregnant women seen in the first
trimester who have low BMI - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

7. No. of pregnant women given iodine

capsules – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
8. No. of pregnant women given one dose
of deworming tablet - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
9. No. of pregnant women screened for
syphilis - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
10. No. of pregnant women tested positive
for syphilis - Total

0 0 0 0
 • NHTS 0
• Non-NHTS 0
11. No. of pregnant women screened for
Hepatitis B - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
18. No. of deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
19. No. of live births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20a. No. of live births with normal birth
weight - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20b. No. of live births with low birth weight
- Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
20c. No. of live births with unknown birth
weight- Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
21. No. of deliveries attended by skilled
health professionals - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col 3)  (Col. 4)
rks Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

24a. No. of deliveries in public health

facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
24b. No. of deliveries in private health
facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
25. No. of non-facility-based deliveries -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
26a. No. of vaginal deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
26b. No. of deliveries by cesarean
section – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
27a. No. of full-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
27b. No. of pre-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B3. Postpartum and Newborn Care
28. No. of postpartum women together
with their newborn who completed at
least 2 postpartum check-ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
 29. No. of postpartum women who
completed iron with folic acid
supplementation - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
30. No. of postpartum women with
Vitamin A supplementation – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
ction C. Child Care and Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)

epB 3 - Total 0 0 0 11. PCV 1 - Total 0 0

0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 12. PCV 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 13. PCV 3 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 14. MMR 1 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
0 0 0 15. MMR 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
1 (November) - Total 0 0 0 20. Td, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
e 1 (November) - Total 0 0 0 21. MR, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

34. Children 12-23 mos. who completed

1 mos. old seen - Total
MNP supplementation - Total
0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
 1 mos. given 1 dose of
35. Children 0-59 mos. seen - Total
100,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos seen - Total 0 0 0 36. Stunted - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos. old given 2
37. Wasted - Total
tamin A 200,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
1 months old who completed
38. Overweight/Obese - Total
lementation - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS

2-23 mos. seen - Total 39. Normal - Total

0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col. 1) (Col 2) (Col 3)

y/o dewormed (2 doses) - 43. Adolescents, 10-19 y/o dewormed

0 0 0 (2 doses) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

ren 12-59 mos. old 50. Diarrhea cases 0-59 mos. received
itamin A - Total 0 0 0 ORS w/ zinc - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old seen 51. Pneumonia cases 0-59 mos. old
0 0 0 seen - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old 52. Pneumonia cases 0-59 mos. old
ORS - Total 0 0 0 completed treatment - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
 To be submitted Quarterly
ous Disease Prevention and Control Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
miasis Prevention and Control E2. Schistosomiasis Prevention and Control (Con't.)
le 5-65 y/o who ingested 7. No. confirmed chronic cases - Total
- Total 0
nts seen - Total 0 8. No. of confirmed cases (acute and
ected cases seen 0 chronic) - Total
clinically diagnosed cases - 9. No. of cases treated - Total
0
rmed acute cases - Total 0 10. No. of confirmed chronic cases
nic clinically diagnosed referred to a hospital facility - Total
al 0
_________________________________________
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
M1
RGY
Total

(Col. 3)

New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
 0 0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0 0
0
0
0 0
0
0
0 0
0
0
 0 0
0
0

Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
 Total
(Col 4)

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Total
(Col 4)
0
0
0
0
0
0

0
0
0
 0
0
0
0
0
0

0
0
0

0
0
0

0
0
0
Total
(Col 4)

0
0
0

0
0
0

0
0
0

0
0
0
 Total
(Col 4)
't.)

Total
(Col 4)
 FHSIS REPORT for the MONTH: ___JANUARY_____
Name of Barangay: _____TAGPAKO_________
Name of BHS: _______________________
Name of Municipality/City: _______________________
Name of Province: ________________________
Projected Population of the Year: _______________________
For submission to RHU/MHC

Section A. Family Planning Services and Dewor

A1. Modern FP Unmet Need Age Total

(Col. 1) (Col. 2) (Col. 3)

10-14 15-19 20-49
1. No. of WRA with unmet
need for modern FP - Total 5 5 5
15
• NHTS 5 5 5 15
• Non-NHTS 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
a. Female Sterilization/ BTL - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
b. Male Sterilization/ NSV-Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
c. Condom - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d. Pills - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
 d.1 Pills-POP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d.2 Pills-COC - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
e. Injectables (DMPA/ POI) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
f. Implant - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g. IUD (IUD-I and IUD-PP) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.1 IUD-I- Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.2 IUD-PP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
h. NFP-LAM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
i. NFP-BBT - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
j. NFP-CMM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
k. NFP-STM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
l. NFP-SDM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
m. Total Current Users 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
Section B. Maternal Care
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
1. No. of pregnant women w/
at least 4 prenatal check-
ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
2. No. of pregnant women
assessed of their nutritional
status during the 1st tri. -Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
c. No. of pregnant women
seen in the first trimester
who have high BMI - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
3. No. of pregnant women for
the first time given 2 doses of
Td vaccination - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
4. No. of pregnant women for
the 2nd or more times given
at least 3 doses of Td
vaccination (Td2 Plus) - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
5. No. of pregnant women who
completed the dose of iron
with folic acid
supplementation - Total 0 0 0 0
 • NHTS 0
• Non-NHTS 0
6. No. of pregnant women who
completed doses of calcium
carbonate supplementation -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
12. No. of pregnant women
tested positive for Hepatitis
B - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
13. No. of pregnant women
screened for HIV - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
14. No. of pregnant women
tested for CBC or Hgb&Hct
count - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
15. No. of pregnant women
tested for CBC or Hgb&Hct
count diagnosed with
anemia - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
16. No. of pregnant women
screened for gestational
diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
17.   No. of pregnant women
tested positive for
gestational diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col 3)  (Col. 4)
 Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
a. No. of deliveries attended
by a doctor - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by a nurse – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
c. No. of deliveries attended
by midwives - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
22. No. of deliveries attended by
non-skilled health
professionals - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
a. No. of deliveries attended
by Hilot/TBA - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by others - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
23. No. of health facility-based
deliveries - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
27c. No. of fetal deaths - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
27d. No. of abortion/
miscarriage - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0

Section C. Child Care a

Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
C1. Immunization Services
1. CPAB - Total 0 0 0 6. DPT-HiB-HepB 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
2. BCG - Total 0 0 0 7. OPV 1 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
3. HepB, within 24 hours. - Total 0 0 0 8. OPV 2 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
4. DPT-HiB-HepB 1 - Total 0 0 0 9. OPV 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
5. DPT-HiB-HepB 2 - Total 0 0 0 10. IPV - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
16. FIC - Total 0 0 0 18. Td, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
17. CIC - Total 0 0 0 19. MR, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
C2. Nutrition Services
22. Newborns initiated on breastfeeding
immediately after birth lasting to 90 mins - 28. Infants 6-11 mos. old seen - Total
Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
23. Preterm/LBW infants given iron 29. Infants 6-11 mos. given 1 dose of
supplementation - Total 0 0 0 Vitamin A 100,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
24. Infants 6 mos. old seen - Total 0 0 0 30. Children 12-59 mos seen - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
25. Infants exclusively breastfed until 6th month - 31. Children 12-59 mos. old given 2
Total 0 0 0 doses of Vitamin A 200,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
26. Infants 6 mos. old initiated to complementary 32. Infant 6-11 months old who completed
feeding with continued breastfeeding - Total 0 0 0 MNP supplementation - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
27. Infants 6 mos. old initiated to complementary
feeding but no longer or never been breastfed 33. Children 12-23 mos. seen - Total
- Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
0
40. 1-19 y/o given 2 doses of deworming drug - 42. SAC, 5-9 y/o dewormed (2 doses) -
Total 0 0 0 Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
41. PSAC, 1-4 y/o dewormed (2 doses) - Total 0 0 0
• NHTS 0
• Non-NHTS 0
0
44. Sick Infants 6-11 mos. old seen - Total 47. Sick Children 12-59 mos. old
0 0 0 received Vitamin A - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
45. Sick Infants 6-11 mos. old received 48. Diarrhea cases 0-59 months old seen
Vitamin A - Total 0 0 0 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
49. Diarrhea cases 0-59 months old
46. Sick Children 12-59 mos. old seen - Total
0 0 0 received ORS - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
 To be submitted Qua
Section E. Infectious Disease Preven
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
E1. Filariasis Prevention and Control E2. Schistosomiasis Prevention and Contro
1. No. of individual examined for lymphatic 1. No. of people 5-65 y/o who ingested
filariasis - Total 0 MDA drugs - Total
2. No. of individual examined found positive for 2. No. of patients seen - Total
lymphatic filariasis - Total 0 3. No. of suspected cases seen
3. No. of lymphatic filariasis cases examined with 4. No. acute clinically diagnosed cases -
manifestation of either lymphedema,hydrocele, Total
elephantiasis - Total
0 5. No. of confirmed acute cases - Total
6. No. of chronic clinically diagnosed
cases - Total
Section F. _________________________
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
 ___JANUARY_____ YEAR: ____2020___

M1
AGPAKO__________________________
_________________________
_________________________

BRGY
________________________
________________________
r submission to RHU/MHC

Services and Deworming for Women of Reproductive Age

Total A3. Deworming Services SES Total

Col. 3) (Col. 1) (Col. 2) (Col. 3)

NHTS Non-NHTS
1. No. of women 20-49 years old given 2 doses of
15 deworming drugs - Total
0 0 0
15
0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
on B. Maternal Care and Services
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

a. Number of pregnant women seen in the

first trimester who have normal BMI -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of pregnant women seen in the first
trimester who have low BMI - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

7. No. of pregnant women given iodine

capsules – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
8. No. of pregnant women given one dose
of deworming tablet - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
9. No. of pregnant women screened for
syphilis - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
10. No. of pregnant women tested positive
for syphilis - Total

0 0 0 0
 • NHTS 0
• Non-NHTS 0
11. No. of pregnant women screened for
Hepatitis B - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
18. No. of deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
19. No. of live births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20a. No. of live births with normal birth
weight - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20b. No. of live births with low birth weight
- Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
20c. No. of live births with unknown birth
weight- Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
21. No. of deliveries attended by skilled
health professionals - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col 3)  (Col. 4)
rks Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

24a. No. of deliveries in public health

facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
24b. No. of deliveries in private health
facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
25. No. of non-facility-based deliveries -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
26a. No. of vaginal deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
26b. No. of deliveries by cesarean
section – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
27a. No. of full-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
27b. No. of pre-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B3. Postpartum and Newborn Care
28. No. of postpartum women together
with their newborn who completed at
least 2 postpartum check-ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
 29. No. of postpartum women who
completed iron with folic acid
supplementation - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
30. No. of postpartum women with
Vitamin A supplementation – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
ction C. Child Care and Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)

epB 3 - Total 0 0 0 11. PCV 1 - Total 0 0

0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 12. PCV 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 13. PCV 3 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 14. MMR 1 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
0 0 0 15. MMR 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
1 (November) - Total 0 0 0 20. Td, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
e 1 (November) - Total 0 0 0 21. MR, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

34. Children 12-23 mos. who completed

1 mos. old seen - Total
MNP supplementation - Total
0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
 1 mos. given 1 dose of
35. Children 0-59 mos. seen - Total
100,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos seen - Total 0 0 0 36. Stunted - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos. old given 2
37. Wasted - Total
tamin A 200,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
1 months old who completed
38. Overweight/Obese - Total
lementation - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS

2-23 mos. seen - Total 39. Normal - Total

0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col. 1) (Col 2) (Col 3)

y/o dewormed (2 doses) - 43. Adolescents, 10-19 y/o dewormed

0 0 0 (2 doses) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

ren 12-59 mos. old 50. Diarrhea cases 0-59 mos. received
itamin A - Total 0 0 0 ORS w/ zinc - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old seen 51. Pneumonia cases 0-59 mos. old
0 0 0 seen - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old 52. Pneumonia cases 0-59 mos. old
ORS - Total 0 0 0 completed treatment - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
 To be submitted Quarterly
ous Disease Prevention and Control Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
miasis Prevention and Control E2. Schistosomiasis Prevention and Control (Con't.)
le 5-65 y/o who ingested 7. No. confirmed chronic cases - Total
- Total 0
nts seen - Total 0 8. No. of confirmed cases (acute and
ected cases seen 0 chronic) - Total
clinically diagnosed cases - 9. No. of cases treated - Total
0
rmed acute cases - Total 0 10. No. of confirmed chronic cases
nic clinically diagnosed referred to a hospital facility - Total
al 0
_________________________________________
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
M1
RGY
Total

(Col. 3)

New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
 0 0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0 0
0
0
0 0
0
0
0 0
0
0
 0 0
0
0

Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
 Total
(Col 4)

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Total
(Col 4)
0
0
0
0
0
0

0
0
0
 0
0
0
0
0
0

0
0
0

0
0
0

0
0
0
Total
(Col 4)

0
0
0

0
0
0

0
0
0

0
0
0
 Total
(Col 4)
't.)

Total
(Col 4)
 FHSIS REPORT for the MONTH: ___JANUARY_____
Name of Barangay: _____TAGPAKO_________
Name of BHS: _______________________
Name of Municipality/City: _______________________
Name of Province: ________________________
Projected Population of the Year: _______________________
For submission to RHU/MHC

Section A. Family Planning Services and Dewor

A1. Modern FP Unmet Need Age Total

(Col. 1) (Col. 2) (Col. 3)

10-14 15-19 20-49
1. No. of WRA with unmet
need for modern FP - Total 5 5 5
15
• NHTS 5 5 5 15
• Non-NHTS 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
a. Female Sterilization/ BTL - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
b. Male Sterilization/ NSV-Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
c. Condom - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d. Pills - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
 d.1 Pills-POP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d.2 Pills-COC - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
e. Injectables (DMPA/ POI) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
f. Implant - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g. IUD (IUD-I and IUD-PP) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.1 IUD-I- Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.2 IUD-PP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
h. NFP-LAM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
i. NFP-BBT - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
j. NFP-CMM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
k. NFP-STM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
l. NFP-SDM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
m. Total Current Users 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
Section B. Maternal Care
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
1. No. of pregnant women w/
at least 4 prenatal check-
ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
2. No. of pregnant women
assessed of their nutritional
status during the 1st tri. -Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
c. No. of pregnant women
seen in the first trimester
who have high BMI - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
3. No. of pregnant women for
the first time given 2 doses of
Td vaccination - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
4. No. of pregnant women for
the 2nd or more times given
at least 3 doses of Td
vaccination (Td2 Plus) - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
5. No. of pregnant women who
completed the dose of iron
with folic acid
supplementation - Total 0 0 0 0
 • NHTS 0
• Non-NHTS 0
6. No. of pregnant women who
completed doses of calcium
carbonate supplementation -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
12. No. of pregnant women
tested positive for Hepatitis
B - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
13. No. of pregnant women
screened for HIV - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
14. No. of pregnant women
tested for CBC or Hgb&Hct
count - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
15. No. of pregnant women
tested for CBC or Hgb&Hct
count diagnosed with
anemia - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
16. No. of pregnant women
screened for gestational
diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
17.   No. of pregnant women
tested positive for
gestational diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col 3)  (Col. 4)
 Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
a. No. of deliveries attended
by a doctor - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by a nurse – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
c. No. of deliveries attended
by midwives - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
22. No. of deliveries attended by
non-skilled health
professionals - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
a. No. of deliveries attended
by Hilot/TBA - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by others - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
23. No. of health facility-based
deliveries - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
27c. No. of fetal deaths - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
27d. No. of abortion/
miscarriage - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0

Section C. Child Care a

Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
C1. Immunization Services
1. CPAB - Total 0 0 0 6. DPT-HiB-HepB 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
2. BCG - Total 0 0 0 7. OPV 1 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
3. HepB, within 24 hours. - Total 0 0 0 8. OPV 2 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
4. DPT-HiB-HepB 1 - Total 0 0 0 9. OPV 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
5. DPT-HiB-HepB 2 - Total 0 0 0 10. IPV - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
16. FIC - Total 0 0 0 18. Td, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
17. CIC - Total 0 0 0 19. MR, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
C2. Nutrition Services
22. Newborns initiated on breastfeeding
immediately after birth lasting to 90 mins - 28. Infants 6-11 mos. old seen - Total
Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
23. Preterm/LBW infants given iron 29. Infants 6-11 mos. given 1 dose of
supplementation - Total 0 0 0 Vitamin A 100,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
24. Infants 6 mos. old seen - Total 0 0 0 30. Children 12-59 mos seen - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
25. Infants exclusively breastfed until 6th month - 31. Children 12-59 mos. old given 2
Total 0 0 0 doses of Vitamin A 200,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
26. Infants 6 mos. old initiated to complementary 32. Infant 6-11 months old who completed
feeding with continued breastfeeding - Total 0 0 0 MNP supplementation - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
27. Infants 6 mos. old initiated to complementary
feeding but no longer or never been breastfed 33. Children 12-23 mos. seen - Total
- Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
0
40. 1-19 y/o given 2 doses of deworming drug - 42. SAC, 5-9 y/o dewormed (2 doses) -
Total 0 0 0 Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
41. PSAC, 1-4 y/o dewormed (2 doses) - Total 0 0 0
• NHTS 0
• Non-NHTS 0
0
44. Sick Infants 6-11 mos. old seen - Total 47. Sick Children 12-59 mos. old
0 0 0 received Vitamin A - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
45. Sick Infants 6-11 mos. old received 48. Diarrhea cases 0-59 months old seen
Vitamin A - Total 0 0 0 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
49. Diarrhea cases 0-59 months old
46. Sick Children 12-59 mos. old seen - Total
0 0 0 received ORS - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
 To be submitted Qua
Section E. Infectious Disease Preven
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
E1. Filariasis Prevention and Control E2. Schistosomiasis Prevention and Contro
1. No. of individual examined for lymphatic 1. No. of people 5-65 y/o who ingested
filariasis - Total 0 MDA drugs - Total
2. No. of individual examined found positive for 2. No. of patients seen - Total
lymphatic filariasis - Total 0 3. No. of suspected cases seen
3. No. of lymphatic filariasis cases examined with 4. No. acute clinically diagnosed cases -
manifestation of either lymphedema,hydrocele, Total
elephantiasis - Total
0 5. No. of confirmed acute cases - Total
6. No. of chronic clinically diagnosed
cases - Total
Section F. _________________________
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
 ___JANUARY_____ YEAR: ____2020___

M1
AGPAKO__________________________
_________________________
_________________________

BRGY
________________________
________________________
r submission to RHU/MHC

Services and Deworming for Women of Reproductive Age

Total A3. Deworming Services SES Total

Col. 3) (Col. 1) (Col. 2) (Col. 3)

NHTS Non-NHTS
1. No. of women 20-49 years old given 2 doses of
15 deworming drugs - Total
0 0 0
15
0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
on B. Maternal Care and Services
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

a. Number of pregnant women seen in the

first trimester who have normal BMI -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of pregnant women seen in the first
trimester who have low BMI - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

7. No. of pregnant women given iodine

capsules – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
8. No. of pregnant women given one dose
of deworming tablet - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
9. No. of pregnant women screened for
syphilis - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
10. No. of pregnant women tested positive
for syphilis - Total

0 0 0 0
 • NHTS 0
• Non-NHTS 0
11. No. of pregnant women screened for
Hepatitis B - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
18. No. of deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
19. No. of live births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20a. No. of live births with normal birth
weight - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20b. No. of live births with low birth weight
- Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
20c. No. of live births with unknown birth
weight- Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
21. No. of deliveries attended by skilled
health professionals - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col 3)  (Col. 4)
rks Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

24a. No. of deliveries in public health

facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
24b. No. of deliveries in private health
facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
25. No. of non-facility-based deliveries -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
26a. No. of vaginal deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
26b. No. of deliveries by cesarean
section – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
27a. No. of full-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
27b. No. of pre-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B3. Postpartum and Newborn Care
28. No. of postpartum women together
with their newborn who completed at
least 2 postpartum check-ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
 29. No. of postpartum women who
completed iron with folic acid
supplementation - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
30. No. of postpartum women with
Vitamin A supplementation – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
ction C. Child Care and Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)

epB 3 - Total 0 0 0 11. PCV 1 - Total 0 0

0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 12. PCV 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 13. PCV 3 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 14. MMR 1 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
0 0 0 15. MMR 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
1 (November) - Total 0 0 0 20. Td, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
e 1 (November) - Total 0 0 0 21. MR, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

34. Children 12-23 mos. who completed

1 mos. old seen - Total
MNP supplementation - Total
0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
 1 mos. given 1 dose of
35. Children 0-59 mos. seen - Total
100,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos seen - Total 0 0 0 36. Stunted - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos. old given 2
37. Wasted - Total
tamin A 200,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
1 months old who completed
38. Overweight/Obese - Total
lementation - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS

2-23 mos. seen - Total 39. Normal - Total

0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col. 1) (Col 2) (Col 3)

y/o dewormed (2 doses) - 43. Adolescents, 10-19 y/o dewormed

0 0 0 (2 doses) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

ren 12-59 mos. old 50. Diarrhea cases 0-59 mos. received
itamin A - Total 0 0 0 ORS w/ zinc - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old seen 51. Pneumonia cases 0-59 mos. old
0 0 0 seen - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old 52. Pneumonia cases 0-59 mos. old
ORS - Total 0 0 0 completed treatment - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
 To be submitted Quarterly
ous Disease Prevention and Control Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
miasis Prevention and Control E2. Schistosomiasis Prevention and Control (Con't.)
le 5-65 y/o who ingested 7. No. confirmed chronic cases - Total
- Total 0
nts seen - Total 0 8. No. of confirmed cases (acute and
ected cases seen 0 chronic) - Total
clinically diagnosed cases - 9. No. of cases treated - Total
0
rmed acute cases - Total 0 10. No. of confirmed chronic cases
nic clinically diagnosed referred to a hospital facility - Total
al 0
_________________________________________
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
M1
RGY
Total

(Col. 3)

New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
 0 0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0 0
0
0
0 0
0
0
0 0
0
0
 0 0
0
0

Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
 Total
(Col 4)

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Total
(Col 4)
0
0
0
0
0
0

0
0
0
 0
0
0
0
0
0

0
0
0

0
0
0

0
0
0
Total
(Col 4)

0
0
0

0
0
0

0
0
0

0
0
0
 Total
(Col 4)
't.)

Total
(Col 4)
Ala

FHSIS REPORT for the MONTH: ___JANUARY_____

Name of Barangay: _____TAGPAKO_________
Name of BHS: _______________________
Name of Municipality/City: _______________________
Name of Province: ________________________
Projected Population of the Year: _______________________
For submission to RHU/MHC

Section A. Family Planning Services and Dewor

A1. Modern FP Unmet Need Age Total

(Col. 1) (Col. 2) (Col. 3)

10-14 15-19 20-49
1. No. of WRA with unmet
need for modern FP - Total 5 5 5
15
• NHTS 5 5 5 15
• Non-NHTS 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
a. Female Sterilization/ BTL - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
b. Male Sterilization/ NSV-Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
c. Condom - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d. Pills - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
 d.1 Pills-POP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d.2 Pills-COC - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
e. Injectables (DMPA/ POI) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
f. Implant - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g. IUD (IUD-I and IUD-PP) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.1 IUD-I- Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.2 IUD-PP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
h. NFP-LAM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
i. NFP-BBT - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
j. NFP-CMM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
k. NFP-STM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
l. NFP-SDM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
m. Total Current Users 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
Section B. Maternal Care
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
1. No. of pregnant women w/
at least 4 prenatal check-
ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
2. No. of pregnant women
assessed of their nutritional
status during the 1st tri. -Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
c. No. of pregnant women
seen in the first trimester
who have high BMI - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
3. No. of pregnant women for
the first time given 2 doses of
Td vaccination - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
4. No. of pregnant women for
the 2nd or more times given
at least 3 doses of Td
vaccination (Td2 Plus) - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
5. No. of pregnant women who
completed the dose of iron
with folic acid
supplementation - Total 0 0 0 0
 • NHTS 0
• Non-NHTS 0
6. No. of pregnant women who
completed doses of calcium
carbonate supplementation -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
12. No. of pregnant women
tested positive for Hepatitis
B - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
13. No. of pregnant women
screened for HIV - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
14. No. of pregnant women
tested for CBC or Hgb&Hct
count - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
15. No. of pregnant women
tested for CBC or Hgb&Hct
count diagnosed with
anemia - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
16. No. of pregnant women
screened for gestational
diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
17.   No. of pregnant women
tested positive for
gestational diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col 3)  (Col. 4)
 Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
a. No. of deliveries attended
by a doctor - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by a nurse – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
c. No. of deliveries attended
by midwives - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
22. No. of deliveries attended by
non-skilled health
professionals - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
a. No. of deliveries attended
by Hilot/TBA - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by others - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
23. No. of health facility-based
deliveries - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
27c. No. of fetal deaths - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
27d. No. of abortion/
miscarriage - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0

Section C. Child Care a

Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
C1. Immunization Services
1. CPAB - Total 0 0 0 6. DPT-HiB-HepB 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
2. BCG - Total 0 0 0 7. OPV 1 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
3. HepB, within 24 hours. - Total 0 0 0 8. OPV 2 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
4. DPT-HiB-HepB 1 - Total 0 0 0 9. OPV 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
5. DPT-HiB-HepB 2 - Total 0 0 0 10. IPV - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
16. FIC - Total 0 0 0 18. Td, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
17. CIC - Total 0 0 0 19. MR, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
C2. Nutrition Services
22. Newborns initiated on breastfeeding
immediately after birth lasting to 90 mins - 28. Infants 6-11 mos. old seen - Total
Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
23. Preterm/LBW infants given iron 29. Infants 6-11 mos. given 1 dose of
supplementation - Total 0 0 0 Vitamin A 100,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
24. Infants 6 mos. old seen - Total 0 0 0 30. Children 12-59 mos seen - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
25. Infants exclusively breastfed until 6th month - 31. Children 12-59 mos. old given 2
Total 0 0 0 doses of Vitamin A 200,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
26. Infants 6 mos. old initiated to complementary 32. Infant 6-11 months old who completed
feeding with continued breastfeeding - Total 0 0 0 MNP supplementation - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
27. Infants 6 mos. old initiated to complementary
feeding but no longer or never been breastfed 33. Children 12-23 mos. seen - Total
- Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
0
40. 1-19 y/o given 2 doses of deworming drug - 42. SAC, 5-9 y/o dewormed (2 doses) -
Total 0 0 0 Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
41. PSAC, 1-4 y/o dewormed (2 doses) - Total 0 0 0
• NHTS 0
• Non-NHTS 0
0
44. Sick Infants 6-11 mos. old seen - Total 47. Sick Children 12-59 mos. old
0 0 0 received Vitamin A - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
45. Sick Infants 6-11 mos. old received 48. Diarrhea cases 0-59 months old seen
Vitamin A - Total 0 0 0 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
49. Diarrhea cases 0-59 months old
46. Sick Children 12-59 mos. old seen - Total
0 0 0 received ORS - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
 To be submitted Qua
Section E. Infectious Disease Preven
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
E1. Filariasis Prevention and Control E2. Schistosomiasis Prevention and Contro
1. No. of individual examined for lymphatic 1. No. of people 5-65 y/o who ingested
filariasis - Total 0 MDA drugs - Total
2. No. of individual examined found positive for 2. No. of patients seen - Total
lymphatic filariasis - Total 0 3. No. of suspected cases seen
3. No. of lymphatic filariasis cases examined with 4. No. acute clinically diagnosed cases -
manifestation of either lymphedema,hydrocele, Total
elephantiasis - Total
0 5. No. of confirmed acute cases - Total
6. No. of chronic clinically diagnosed
cases - Total
Section F. _________________________
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
 ___JANUARY_____ YEAR: ____2020___

M1
AGPAKO__________________________
_________________________
_________________________

BRGY
________________________
________________________
r submission to RHU/MHC

Services and Deworming for Women of Reproductive Age

Total A3. Deworming Services SES Total

Col. 3) (Col. 1) (Col. 2) (Col. 3)

NHTS Non-NHTS
1. No. of women 20-49 years old given 2 doses of
15 deworming drugs - Total
0 0 0
15
0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
on B. Maternal Care and Services
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

a. Number of pregnant women seen in the

first trimester who have normal BMI -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of pregnant women seen in the first
trimester who have low BMI - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

7. No. of pregnant women given iodine

capsules – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
8. No. of pregnant women given one dose
of deworming tablet - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
9. No. of pregnant women screened for
syphilis - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
10. No. of pregnant women tested positive
for syphilis - Total

0 0 0 0
 • NHTS 0
• Non-NHTS 0
11. No. of pregnant women screened for
Hepatitis B - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
18. No. of deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
19. No. of live births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20a. No. of live births with normal birth
weight - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20b. No. of live births with low birth weight
- Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
20c. No. of live births with unknown birth
weight- Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
21. No. of deliveries attended by skilled
health professionals - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col 3)  (Col. 4)
rks Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

24a. No. of deliveries in public health

facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
24b. No. of deliveries in private health
facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
25. No. of non-facility-based deliveries -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
26a. No. of vaginal deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
26b. No. of deliveries by cesarean
section – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
27a. No. of full-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
27b. No. of pre-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B3. Postpartum and Newborn Care
28. No. of postpartum women together
with their newborn who completed at
least 2 postpartum check-ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
 29. No. of postpartum women who
completed iron with folic acid
supplementation - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
30. No. of postpartum women with
Vitamin A supplementation – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
ction C. Child Care and Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)

epB 3 - Total 0 0 0 11. PCV 1 - Total 0 0

0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 12. PCV 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 13. PCV 3 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 14. MMR 1 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
0 0 0 15. MMR 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
1 (November) - Total 0 0 0 20. Td, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
e 1 (November) - Total 0 0 0 21. MR, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

34. Children 12-23 mos. who completed

1 mos. old seen - Total
MNP supplementation - Total
0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
 1 mos. given 1 dose of
35. Children 0-59 mos. seen - Total
100,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos seen - Total 0 0 0 36. Stunted - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos. old given 2
37. Wasted - Total
tamin A 200,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
1 months old who completed
38. Overweight/Obese - Total
lementation - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS

2-23 mos. seen - Total 39. Normal - Total

0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col. 1) (Col 2) (Col 3)

y/o dewormed (2 doses) - 43. Adolescents, 10-19 y/o dewormed

0 0 0 (2 doses) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

ren 12-59 mos. old 50. Diarrhea cases 0-59 mos. received
itamin A - Total 0 0 0 ORS w/ zinc - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old seen 51. Pneumonia cases 0-59 mos. old
0 0 0 seen - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old 52. Pneumonia cases 0-59 mos. old
ORS - Total 0 0 0 completed treatment - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
 To be submitted Quarterly
ous Disease Prevention and Control Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
miasis Prevention and Control E2. Schistosomiasis Prevention and Control (Con't.)
le 5-65 y/o who ingested 7. No. confirmed chronic cases - Total
- Total 0
nts seen - Total 0 8. No. of confirmed cases (acute and
ected cases seen 0 chronic) - Total
clinically diagnosed cases - 9. No. of cases treated - Total
0
rmed acute cases - Total 0 10. No. of confirmed chronic cases
nic clinically diagnosed referred to a hospital facility - Total
al 0
_________________________________________
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
M1
RGY
Total

(Col. 3)

New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
 0 0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0 0
0
0
0 0
0
0
0 0
0
0
 0 0
0
0

Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
 Total
(Col 4)

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Total
(Col 4)
0
0
0
0
0
0

0
0
0
 0
0
0
0
0
0

0
0
0

0
0
0

0
0
0
Total
(Col 4)

0
0
0

0
0
0

0
0
0

0
0
0
 Total
(Col 4)
't.)

Total
(Col 4)
 FHSIS REPORT for the MONTH: ___JANUARY_____
Name of Barangay: _____TAGPAKO_________
Name of BHS: _______________________
Name of Municipality/City: _______________________
Name of Province: ________________________
Projected Population of the Year: _______________________
For submission to RHU/MHC

Section A. Family Planning Services and Dewor

A1. Modern FP Unmet Need Age Total

(Col. 1) (Col. 2) (Col. 3)

10-14 15-19 20-49
1. No. of WRA with unmet
need for modern FP - Total 5 5 5
15
• NHTS 5 5 5 15
• Non-NHTS 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
a. Female Sterilization/ BTL - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
b. Male Sterilization/ NSV-Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
c. Condom - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d. Pills - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
 d.1 Pills-POP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d.2 Pills-COC - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
e. Injectables (DMPA/ POI) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
f. Implant - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g. IUD (IUD-I and IUD-PP) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.1 IUD-I- Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.2 IUD-PP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
h. NFP-LAM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
i. NFP-BBT - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
j. NFP-CMM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
k. NFP-STM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
l. NFP-SDM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
m. Total Current Users 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
Section B. Maternal Care
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
1. No. of pregnant women w/
at least 4 prenatal check-
ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
2. No. of pregnant women
assessed of their nutritional
status during the 1st tri. -Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
c. No. of pregnant women
seen in the first trimester
who have high BMI - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
3. No. of pregnant women for
the first time given 2 doses of
Td vaccination - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
4. No. of pregnant women for
the 2nd or more times given
at least 3 doses of Td
vaccination (Td2 Plus) - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
5. No. of pregnant women who
completed the dose of iron
with folic acid
supplementation - Total 0 0 0 0
 • NHTS 0
• Non-NHTS 0
6. No. of pregnant women who
completed doses of calcium
carbonate supplementation -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
12. No. of pregnant women
tested positive for Hepatitis
B - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
13. No. of pregnant women
screened for HIV - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
14. No. of pregnant women
tested for CBC or Hgb&Hct
count - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
15. No. of pregnant women
tested for CBC or Hgb&Hct
count diagnosed with
anemia - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
16. No. of pregnant women
screened for gestational
diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
17.   No. of pregnant women
tested positive for
gestational diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col 3)  (Col. 4)
 Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
a. No. of deliveries attended
by a doctor - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by a nurse – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
c. No. of deliveries attended
by midwives - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
22. No. of deliveries attended by
non-skilled health
professionals - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
a. No. of deliveries attended
by Hilot/TBA - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by others - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
23. No. of health facility-based
deliveries - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
27c. No. of fetal deaths - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
27d. No. of abortion/
miscarriage - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0

Section C. Child Care a

Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
C1. Immunization Services
1. CPAB - Total 0 0 0 6. DPT-HiB-HepB 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
2. BCG - Total 0 0 0 7. OPV 1 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
3. HepB, within 24 hours. - Total 0 0 0 8. OPV 2 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
4. DPT-HiB-HepB 1 - Total 0 0 0 9. OPV 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
5. DPT-HiB-HepB 2 - Total 0 0 0 10. IPV - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
16. FIC - Total 0 0 0 18. Td, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
17. CIC - Total 0 0 0 19. MR, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
C2. Nutrition Services
22. Newborns initiated on breastfeeding
immediately after birth lasting to 90 mins - 28. Infants 6-11 mos. old seen - Total
Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
23. Preterm/LBW infants given iron 29. Infants 6-11 mos. given 1 dose of
supplementation - Total 0 0 0 Vitamin A 100,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
24. Infants 6 mos. old seen - Total 0 0 0 30. Children 12-59 mos seen - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
25. Infants exclusively breastfed until 6th month - 31. Children 12-59 mos. old given 2
Total 0 0 0 doses of Vitamin A 200,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
26. Infants 6 mos. old initiated to complementary 32. Infant 6-11 months old who completed
feeding with continued breastfeeding - Total 0 0 0 MNP supplementation - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
27. Infants 6 mos. old initiated to complementary
feeding but no longer or never been breastfed 33. Children 12-23 mos. seen - Total
- Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
0
40. 1-19 y/o given 2 doses of deworming drug - 42. SAC, 5-9 y/o dewormed (2 doses) -
Total 0 0 0 Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
41. PSAC, 1-4 y/o dewormed (2 doses) - Total 0 0 0
• NHTS 0
• Non-NHTS 0
0
44. Sick Infants 6-11 mos. old seen - Total 47. Sick Children 12-59 mos. old
0 0 0 received Vitamin A - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
45. Sick Infants 6-11 mos. old received 48. Diarrhea cases 0-59 months old seen
Vitamin A - Total 0 0 0 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
49. Diarrhea cases 0-59 months old
46. Sick Children 12-59 mos. old seen - Total
0 0 0 received ORS - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
 To be submitted Qua
Section E. Infectious Disease Preven
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
E1. Filariasis Prevention and Control E2. Schistosomiasis Prevention and Contro
1. No. of individual examined for lymphatic 1. No. of people 5-65 y/o who ingested
filariasis - Total 0 MDA drugs - Total
2. No. of individual examined found positive for 2. No. of patients seen - Total
lymphatic filariasis - Total 0 3. No. of suspected cases seen
3. No. of lymphatic filariasis cases examined with 4. No. acute clinically diagnosed cases -
manifestation of either lymphedema,hydrocele, Total
elephantiasis - Total
0 5. No. of confirmed acute cases - Total
6. No. of chronic clinically diagnosed
cases - Total
Section F. _________________________
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
 ___JANUARY_____ YEAR: ____2020___

M1
AGPAKO__________________________
_________________________
_________________________

BRGY
________________________
________________________
r submission to RHU/MHC

Services and Deworming for Women of Reproductive Age

Total A3. Deworming Services SES Total

Col. 3) (Col. 1) (Col. 2) (Col. 3)

NHTS Non-NHTS
1. No. of women 20-49 years old given 2 doses of
15 deworming drugs - Total
0 0 0
15
0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
on B. Maternal Care and Services
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

a. Number of pregnant women seen in the

first trimester who have normal BMI -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of pregnant women seen in the first
trimester who have low BMI - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

7. No. of pregnant women given iodine

capsules – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
8. No. of pregnant women given one dose
of deworming tablet - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
9. No. of pregnant women screened for
syphilis - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
10. No. of pregnant women tested positive
for syphilis - Total

0 0 0 0
 • NHTS 0
• Non-NHTS 0
11. No. of pregnant women screened for
Hepatitis B - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
18. No. of deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
19. No. of live births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20a. No. of live births with normal birth
weight - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20b. No. of live births with low birth weight
- Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
20c. No. of live births with unknown birth
weight- Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
21. No. of deliveries attended by skilled
health professionals - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col 3)  (Col. 4)
rks Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

24a. No. of deliveries in public health

facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
24b. No. of deliveries in private health
facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
25. No. of non-facility-based deliveries -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
26a. No. of vaginal deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
26b. No. of deliveries by cesarean
section – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
27a. No. of full-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
27b. No. of pre-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B3. Postpartum and Newborn Care
28. No. of postpartum women together
with their newborn who completed at
least 2 postpartum check-ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
 29. No. of postpartum women who
completed iron with folic acid
supplementation - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
30. No. of postpartum women with
Vitamin A supplementation – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
ction C. Child Care and Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)

epB 3 - Total 0 0 0 11. PCV 1 - Total 0 0

0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 12. PCV 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 13. PCV 3 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 14. MMR 1 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
0 0 0 15. MMR 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
1 (November) - Total 0 0 0 20. Td, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
e 1 (November) - Total 0 0 0 21. MR, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

34. Children 12-23 mos. who completed

1 mos. old seen - Total
MNP supplementation - Total
0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
 1 mos. given 1 dose of
35. Children 0-59 mos. seen - Total
100,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos seen - Total 0 0 0 36. Stunted - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos. old given 2
37. Wasted - Total
tamin A 200,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
1 months old who completed
38. Overweight/Obese - Total
lementation - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS

2-23 mos. seen - Total 39. Normal - Total

0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col. 1) (Col 2) (Col 3)

y/o dewormed (2 doses) - 43. Adolescents, 10-19 y/o dewormed

0 0 0 (2 doses) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

ren 12-59 mos. old 50. Diarrhea cases 0-59 mos. received
itamin A - Total 0 0 0 ORS w/ zinc - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old seen 51. Pneumonia cases 0-59 mos. old
0 0 0 seen - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old 52. Pneumonia cases 0-59 mos. old
ORS - Total 0 0 0 completed treatment - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
 To be submitted Quarterly
ous Disease Prevention and Control Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
miasis Prevention and Control E2. Schistosomiasis Prevention and Control (Con't.)
le 5-65 y/o who ingested 7. No. confirmed chronic cases - Total
- Total 0
nts seen - Total 0 8. No. of confirmed cases (acute and
ected cases seen 0 chronic) - Total
clinically diagnosed cases - 9. No. of cases treated - Total
0
rmed acute cases - Total 0 10. No. of confirmed chronic cases
nic clinically diagnosed referred to a hospital facility - Total
al 0
_________________________________________
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
M1
RGY
Total

(Col. 3)

New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
 0 0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0 0
0
0
0 0
0
0
0 0
0
0
 0 0
0
0

Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
 Total
(Col 4)

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Total
(Col 4)
0
0
0
0
0
0

0
0
0
 0
0
0
0
0
0

0
0
0

0
0
0

0
0
0
Total
(Col 4)

0
0
0

0
0
0

0
0
0

0
0
0
 Total
(Col 4)
't.)

Total
(Col 4)
 FHSIS REPORT for the MONTH: ___JANUARY_____
Name of Barangay: _____TAGPAKO_________
Name of BHS: _______________________
Name of Municipality/City: _______________________
Name of Province: ________________________
Projected Population of the Year: _______________________
For submission to RHU/MHC

Section A. Family Planning Services and Dewor

A1. Modern FP Unmet Need Age Total

(Col. 1) (Col. 2) (Col. 3)

10-14 15-19 20-49
1. No. of WRA with unmet
need for modern FP - Total 5 5 5
15
• NHTS 5 5 5 15
• Non-NHTS 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
a. Female Sterilization/ BTL - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
b. Male Sterilization/ NSV-Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
c. Condom - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d. Pills - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
 d.1 Pills-POP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d.2 Pills-COC - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
e. Injectables (DMPA/ POI) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
f. Implant - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g. IUD (IUD-I and IUD-PP) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.1 IUD-I- Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.2 IUD-PP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
h. NFP-LAM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
i. NFP-BBT - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
j. NFP-CMM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
k. NFP-STM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
l. NFP-SDM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
m. Total Current Users 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
Section B. Maternal Care
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
1. No. of pregnant women w/
at least 4 prenatal check-
ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
2. No. of pregnant women
assessed of their nutritional
status during the 1st tri. -Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
c. No. of pregnant women
seen in the first trimester
who have high BMI - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
3. No. of pregnant women for
the first time given 2 doses of
Td vaccination - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
4. No. of pregnant women for
the 2nd or more times given
at least 3 doses of Td
vaccination (Td2 Plus) - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
5. No. of pregnant women who
completed the dose of iron
with folic acid
supplementation - Total 0 0 0 0
 • NHTS 0
• Non-NHTS 0
6. No. of pregnant women who
completed doses of calcium
carbonate supplementation -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
12. No. of pregnant women
tested positive for Hepatitis
B - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
13. No. of pregnant women
screened for HIV - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
14. No. of pregnant women
tested for CBC or Hgb&Hct
count - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
15. No. of pregnant women
tested for CBC or Hgb&Hct
count diagnosed with
anemia - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
16. No. of pregnant women
screened for gestational
diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
17.   No. of pregnant women
tested positive for
gestational diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col 3)  (Col. 4)
 Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
a. No. of deliveries attended
by a doctor - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by a nurse – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
c. No. of deliveries attended
by midwives - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
22. No. of deliveries attended by
non-skilled health
professionals - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
a. No. of deliveries attended
by Hilot/TBA - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by others - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
23. No. of health facility-based
deliveries - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
27c. No. of fetal deaths - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
27d. No. of abortion/
miscarriage - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0

Section C. Child Care a

Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
C1. Immunization Services
1. CPAB - Total 0 0 0 6. DPT-HiB-HepB 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
2. BCG - Total 0 0 0 7. OPV 1 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
3. HepB, within 24 hours. - Total 0 0 0 8. OPV 2 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
4. DPT-HiB-HepB 1 - Total 0 0 0 9. OPV 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
5. DPT-HiB-HepB 2 - Total 0 0 0 10. IPV - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
16. FIC - Total 0 0 0 18. Td, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
17. CIC - Total 0 0 0 19. MR, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
C2. Nutrition Services
22. Newborns initiated on breastfeeding
immediately after birth lasting to 90 mins - 28. Infants 6-11 mos. old seen - Total
Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
23. Preterm/LBW infants given iron 29. Infants 6-11 mos. given 1 dose of
supplementation - Total 0 0 0 Vitamin A 100,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
24. Infants 6 mos. old seen - Total 0 0 0 30. Children 12-59 mos seen - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
25. Infants exclusively breastfed until 6th month - 31. Children 12-59 mos. old given 2
Total 0 0 0 doses of Vitamin A 200,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
26. Infants 6 mos. old initiated to complementary 32. Infant 6-11 months old who completed
feeding with continued breastfeeding - Total 0 0 0 MNP supplementation - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
27. Infants 6 mos. old initiated to complementary
feeding but no longer or never been breastfed 33. Children 12-23 mos. seen - Total
- Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
0
40. 1-19 y/o given 2 doses of deworming drug - 42. SAC, 5-9 y/o dewormed (2 doses) -
Total 0 0 0 Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
41. PSAC, 1-4 y/o dewormed (2 doses) - Total 0 0 0
• NHTS 0
• Non-NHTS 0
0
44. Sick Infants 6-11 mos. old seen - Total 47. Sick Children 12-59 mos. old
0 0 0 received Vitamin A - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
45. Sick Infants 6-11 mos. old received 48. Diarrhea cases 0-59 months old seen
Vitamin A - Total 0 0 0 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
49. Diarrhea cases 0-59 months old
46. Sick Children 12-59 mos. old seen - Total
0 0 0 received ORS - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
 To be submitted Qua
Section E. Infectious Disease Preven
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
E1. Filariasis Prevention and Control E2. Schistosomiasis Prevention and Contro
1. No. of individual examined for lymphatic 1. No. of people 5-65 y/o who ingested
filariasis - Total 0 MDA drugs - Total
2. No. of individual examined found positive for 2. No. of patients seen - Total
lymphatic filariasis - Total 0 3. No. of suspected cases seen
3. No. of lymphatic filariasis cases examined with 4. No. acute clinically diagnosed cases -
manifestation of either lymphedema,hydrocele, Total
elephantiasis - Total
0 5. No. of confirmed acute cases - Total
6. No. of chronic clinically diagnosed
cases - Total
Section F. _________________________
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
 ___JANUARY_____ YEAR: ____2020___

M1
AGPAKO__________________________
_________________________
_________________________

BRGY
________________________
________________________
r submission to RHU/MHC

Services and Deworming for Women of Reproductive Age

Total A3. Deworming Services SES Total

Col. 3) (Col. 1) (Col. 2) (Col. 3)

NHTS Non-NHTS
1. No. of women 20-49 years old given 2 doses of
15 deworming drugs - Total
0 0 0
15
0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
on B. Maternal Care and Services
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

a. Number of pregnant women seen in the

first trimester who have normal BMI -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of pregnant women seen in the first
trimester who have low BMI - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

7. No. of pregnant women given iodine

capsules – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
8. No. of pregnant women given one dose
of deworming tablet - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
9. No. of pregnant women screened for
syphilis - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
10. No. of pregnant women tested positive
for syphilis - Total

0 0 0 0
 • NHTS 0
• Non-NHTS 0
11. No. of pregnant women screened for
Hepatitis B - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
18. No. of deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
19. No. of live births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20a. No. of live births with normal birth
weight - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20b. No. of live births with low birth weight
- Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
20c. No. of live births with unknown birth
weight- Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
21. No. of deliveries attended by skilled
health professionals - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col 3)  (Col. 4)
rks Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

24a. No. of deliveries in public health

facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
24b. No. of deliveries in private health
facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
25. No. of non-facility-based deliveries -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
26a. No. of vaginal deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
26b. No. of deliveries by cesarean
section – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
27a. No. of full-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
27b. No. of pre-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B3. Postpartum and Newborn Care
28. No. of postpartum women together
with their newborn who completed at
least 2 postpartum check-ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
 29. No. of postpartum women who
completed iron with folic acid
supplementation - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
30. No. of postpartum women with
Vitamin A supplementation – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
ction C. Child Care and Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)

epB 3 - Total 0 0 0 11. PCV 1 - Total 0 0

0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 12. PCV 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 13. PCV 3 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 14. MMR 1 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
0 0 0 15. MMR 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
1 (November) - Total 0 0 0 20. Td, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
e 1 (November) - Total 0 0 0 21. MR, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

34. Children 12-23 mos. who completed

1 mos. old seen - Total
MNP supplementation - Total
0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
 1 mos. given 1 dose of
35. Children 0-59 mos. seen - Total
100,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos seen - Total 0 0 0 36. Stunted - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos. old given 2
37. Wasted - Total
tamin A 200,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
1 months old who completed
38. Overweight/Obese - Total
lementation - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS

2-23 mos. seen - Total 39. Normal - Total

0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col. 1) (Col 2) (Col 3)

y/o dewormed (2 doses) - 43. Adolescents, 10-19 y/o dewormed

0 0 0 (2 doses) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

ren 12-59 mos. old 50. Diarrhea cases 0-59 mos. received
itamin A - Total 0 0 0 ORS w/ zinc - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old seen 51. Pneumonia cases 0-59 mos. old
0 0 0 seen - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old 52. Pneumonia cases 0-59 mos. old
ORS - Total 0 0 0 completed treatment - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
 To be submitted Quarterly
ous Disease Prevention and Control Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
miasis Prevention and Control E2. Schistosomiasis Prevention and Control (Con't.)
le 5-65 y/o who ingested 7. No. confirmed chronic cases - Total
- Total 0
nts seen - Total 0 8. No. of confirmed cases (acute and
ected cases seen 0 chronic) - Total
clinically diagnosed cases - 9. No. of cases treated - Total
0
rmed acute cases - Total 0 10. No. of confirmed chronic cases
nic clinically diagnosed referred to a hospital facility - Total
al 0
_________________________________________
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
M1
RGY
Total

(Col. 3)

New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
 0 0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0 0
0
0
0 0
0
0
0 0
0
0
 0 0
0
0

Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
 Total
(Col 4)

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Total
(Col 4)
0
0
0
0
0
0

0
0
0
 0
0
0
0
0
0

0
0
0

0
0
0

0
0
0
Total
(Col 4)

0
0
0

0
0
0

0
0
0

0
0
0
 Total
(Col 4)
't.)

Total
(Col 4)
 FHSIS REPORT for the MONTH: ___JANUARY_____
Name of Barangay: _____TAGPAKO_________
Name of BHS: _______________________
Name of Municipality/City: _______________________
Name of Province: ________________________
Projected Population of the Year: _______________________
For submission to RHU/MHC

Section A. Family Planning Services and Dewor

A1. Modern FP Unmet Need Age Total

(Col. 1) (Col. 2) (Col. 3)

10-14 15-19 20-49
1. No. of WRA with unmet
need for modern FP - Total 5 5 5
15
• NHTS 5 5 5 15
• Non-NHTS 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
a. Female Sterilization/ BTL - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
b. Male Sterilization/ NSV-Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
c. Condom - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d. Pills - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
 d.1 Pills-POP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d.2 Pills-COC - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
e. Injectables (DMPA/ POI) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
f. Implant - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g. IUD (IUD-I and IUD-PP) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.1 IUD-I- Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.2 IUD-PP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
h. NFP-LAM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
i. NFP-BBT - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
j. NFP-CMM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
k. NFP-STM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
l. NFP-SDM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
m. Total Current Users 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
Section B. Maternal Care
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
1. No. of pregnant women w/
at least 4 prenatal check-
ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
2. No. of pregnant women
assessed of their nutritional
status during the 1st tri. -Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
c. No. of pregnant women
seen in the first trimester
who have high BMI - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
3. No. of pregnant women for
the first time given 2 doses of
Td vaccination - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
4. No. of pregnant women for
the 2nd or more times given
at least 3 doses of Td
vaccination (Td2 Plus) - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
5. No. of pregnant women who
completed the dose of iron
with folic acid
supplementation - Total 0 0 0 0
 • NHTS 0
• Non-NHTS 0
6. No. of pregnant women who
completed doses of calcium
carbonate supplementation -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
12. No. of pregnant women
tested positive for Hepatitis
B - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
13. No. of pregnant women
screened for HIV - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
14. No. of pregnant women
tested for CBC or Hgb&Hct
count - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
15. No. of pregnant women
tested for CBC or Hgb&Hct
count diagnosed with
anemia - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
16. No. of pregnant women
screened for gestational
diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
17.   No. of pregnant women
tested positive for
gestational diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col 3)  (Col. 4)
 Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
a. No. of deliveries attended
by a doctor - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by a nurse – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
c. No. of deliveries attended
by midwives - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
22. No. of deliveries attended by
non-skilled health
professionals - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
a. No. of deliveries attended
by Hilot/TBA - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by others - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
23. No. of health facility-based
deliveries - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
27c. No. of fetal deaths - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
27d. No. of abortion/
miscarriage - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0

Section C. Child Care a

Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
C1. Immunization Services
1. CPAB - Total 0 0 0 6. DPT-HiB-HepB 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
2. BCG - Total 0 0 0 7. OPV 1 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
3. HepB, within 24 hours. - Total 0 0 0 8. OPV 2 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
4. DPT-HiB-HepB 1 - Total 0 0 0 9. OPV 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
5. DPT-HiB-HepB 2 - Total 0 0 0 10. IPV - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
16. FIC - Total 0 0 0 18. Td, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
17. CIC - Total 0 0 0 19. MR, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
C2. Nutrition Services
22. Newborns initiated on breastfeeding
immediately after birth lasting to 90 mins - 28. Infants 6-11 mos. old seen - Total
Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
23. Preterm/LBW infants given iron 29. Infants 6-11 mos. given 1 dose of
supplementation - Total 0 0 0 Vitamin A 100,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
24. Infants 6 mos. old seen - Total 0 0 0 30. Children 12-59 mos seen - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
25. Infants exclusively breastfed until 6th month - 31. Children 12-59 mos. old given 2
Total 0 0 0 doses of Vitamin A 200,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
26. Infants 6 mos. old initiated to complementary 32. Infant 6-11 months old who completed
feeding with continued breastfeeding - Total 0 0 0 MNP supplementation - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
27. Infants 6 mos. old initiated to complementary
feeding but no longer or never been breastfed 33. Children 12-23 mos. seen - Total
- Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
0
40. 1-19 y/o given 2 doses of deworming drug - 42. SAC, 5-9 y/o dewormed (2 doses) -
Total 0 0 0 Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
41. PSAC, 1-4 y/o dewormed (2 doses) - Total 0 0 0
• NHTS 0
• Non-NHTS 0
0
44. Sick Infants 6-11 mos. old seen - Total 47. Sick Children 12-59 mos. old
0 0 0 received Vitamin A - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
45. Sick Infants 6-11 mos. old received 48. Diarrhea cases 0-59 months old seen
Vitamin A - Total 0 0 0 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
49. Diarrhea cases 0-59 months old
46. Sick Children 12-59 mos. old seen - Total
0 0 0 received ORS - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
 To be submitted Qua
Section E. Infectious Disease Preven
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
E1. Filariasis Prevention and Control E2. Schistosomiasis Prevention and Contro
1. No. of individual examined for lymphatic 1. No. of people 5-65 y/o who ingested
filariasis - Total 0 MDA drugs - Total
2. No. of individual examined found positive for 2. No. of patients seen - Total
lymphatic filariasis - Total 0 3. No. of suspected cases seen
3. No. of lymphatic filariasis cases examined with 4. No. acute clinically diagnosed cases -
manifestation of either lymphedema,hydrocele, Total
elephantiasis - Total
0 5. No. of confirmed acute cases - Total
6. No. of chronic clinically diagnosed
cases - Total
Section F. _________________________
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
 ___JANUARY_____ YEAR: ____2020___

M1
AGPAKO__________________________
_________________________
_________________________

BRGY
________________________
________________________
r submission to RHU/MHC

Services and Deworming for Women of Reproductive Age

Total A3. Deworming Services SES Total

Col. 3) (Col. 1) (Col. 2) (Col. 3)

NHTS Non-NHTS
1. No. of women 20-49 years old given 2 doses of
15 deworming drugs - Total
0 0 0
15
0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
on B. Maternal Care and Services
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

a. Number of pregnant women seen in the

first trimester who have normal BMI -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of pregnant women seen in the first
trimester who have low BMI - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

7. No. of pregnant women given iodine

capsules – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
8. No. of pregnant women given one dose
of deworming tablet - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
9. No. of pregnant women screened for
syphilis - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
10. No. of pregnant women tested positive
for syphilis - Total

0 0 0 0
 • NHTS 0
• Non-NHTS 0
11. No. of pregnant women screened for
Hepatitis B - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
18. No. of deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
19. No. of live births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20a. No. of live births with normal birth
weight - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20b. No. of live births with low birth weight
- Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
20c. No. of live births with unknown birth
weight- Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
21. No. of deliveries attended by skilled
health professionals - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col 3)  (Col. 4)
rks Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

24a. No. of deliveries in public health

facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
24b. No. of deliveries in private health
facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
25. No. of non-facility-based deliveries -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
26a. No. of vaginal deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
26b. No. of deliveries by cesarean
section – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
27a. No. of full-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
27b. No. of pre-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B3. Postpartum and Newborn Care
28. No. of postpartum women together
with their newborn who completed at
least 2 postpartum check-ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
 29. No. of postpartum women who
completed iron with folic acid
supplementation - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
30. No. of postpartum women with
Vitamin A supplementation – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
ction C. Child Care and Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)

epB 3 - Total 0 0 0 11. PCV 1 - Total 0 0

0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 12. PCV 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 13. PCV 3 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 14. MMR 1 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
0 0 0 15. MMR 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
1 (November) - Total 0 0 0 20. Td, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
e 1 (November) - Total 0 0 0 21. MR, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

34. Children 12-23 mos. who completed

1 mos. old seen - Total
MNP supplementation - Total
0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
 1 mos. given 1 dose of
35. Children 0-59 mos. seen - Total
100,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos seen - Total 0 0 0 36. Stunted - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos. old given 2
37. Wasted - Total
tamin A 200,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
1 months old who completed
38. Overweight/Obese - Total
lementation - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS

2-23 mos. seen - Total 39. Normal - Total

0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col. 1) (Col 2) (Col 3)

y/o dewormed (2 doses) - 43. Adolescents, 10-19 y/o dewormed

0 0 0 (2 doses) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

ren 12-59 mos. old 50. Diarrhea cases 0-59 mos. received
itamin A - Total 0 0 0 ORS w/ zinc - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old seen 51. Pneumonia cases 0-59 mos. old
0 0 0 seen - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old 52. Pneumonia cases 0-59 mos. old
ORS - Total 0 0 0 completed treatment - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
 To be submitted Quarterly
ous Disease Prevention and Control Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
miasis Prevention and Control E2. Schistosomiasis Prevention and Control (Con't.)
le 5-65 y/o who ingested 7. No. confirmed chronic cases - Total
- Total 0
nts seen - Total 0 8. No. of confirmed cases (acute and
ected cases seen 0 chronic) - Total
clinically diagnosed cases - 9. No. of cases treated - Total
0
rmed acute cases - Total 0 10. No. of confirmed chronic cases
nic clinically diagnosed referred to a hospital facility - Total
al 0
_________________________________________
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
M1
RGY
Total

(Col. 3)

New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
 0 0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0 0
0
0
0 0
0
0
0 0
0
0
 0 0
0
0

Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
 Total
(Col 4)

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Total
(Col 4)
0
0
0
0
0
0

0
0
0
 0
0
0
0
0
0

0
0
0

0
0
0

0
0
0
Total
(Col 4)

0
0
0

0
0
0

0
0
0

0
0
0
 Total
(Col 4)
't.)

Total
(Col 4)
 FHSIS REPORT for the MONTH: ___MAY_____ YE
Name of Barangay: MIMBUNTONG
Name of BHS: MIMBUNTONG
Name of Municipality/City: GINGOOG CITY
Name of Province: MISAMIS ORIENTAL
Projected Population of the Year: 654
For submission to RHU/MHC

Section A. Family Planning Services and Dewor

A1. Modern FP Unmet Need Age Total

(Col. 1) (Col. 2) (Col. 3)

10-14 15-19 20-49
1. No. of WRA with unmet
need for modern FP - Total 5 5 5
15
• NHTS 5 5 5 15
• Non-NHTS 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
a. Female Sterilization/ BTL -
Total 0 0 4 4 0 0 0 0 0
• NHTS 0 0 0 0 0 0 0 0 0
• Non-NHTS 0 0 4 4 0 0 0 0 0
b. Male Sterilization/ NSV-Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0 0 0 0 0 0 0 0
• Non-NHTS 0 0 0 0 0 0 0 0 0
c. Condom - Total 0 0 2 2 0 0 0 0 0
• NHTS 0 0 0 0 0 0 0 0 0
• Non-NHTS 0 0 2 2 0 0 0 0 0
d. Pills - Total 0 2 45 47 0 2 0 2 0
• NHTS 0 0 7 7 0 0 0 0 0
• Non-NHTS 0 0 38 38 0 0 0 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
 d.1 Pills-POP - Total 0 2 0 2 0 0 0 0 0
• NHTS 0 0 0 0 0 0 0 0 0
• Non-NHTS 0 0 0 0 0 0 0 0 0
d.2 Pills-COC - Total 0 0 45 45 0 0 0 0 0
• NHTS 0 0 7 7 0 0 0 0 0
• Non-NHTS 0 0 38 38 0 0 0 0 0
e. Injectables (DMPA/ POI) -
Total 0 0 14 14 0 0 0 0 0
• NHTS 0 0 0 0 0 0 0 0 0
• Non-NHTS 0 0 14 14 0 0 0 0 0
f. Implant - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0 0 0 0 0 0 0 0
• Non-NHTS 0 0 0 0 0 0 0 0 0
g. IUD (IUD-I and IUD-PP) -
Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0 0 0 0 0 0 0 0
• Non-NHTS 0 0 0 0 0 0 0 0 0
g.1 IUD-I- Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0 0 0 0 0 0 0 0
• Non-NHTS 0 0 0 0 0 0 0 0 0
g.2 IUD-PP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0 0 0 0 0 0 0 0
• Non-NHTS 0 0 0 0 0 0 0 0 0
h. NFP-LAM - Total 0 2 3 5 0 0 0 0 0
• NHTS 0 0 0 0 0 0 0 0 0
• Non-NHTS 0 2 3 5 0 0 0 0 0
i. NFP-BBT - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0 0 0 0 0 0 0 0
• Non-NHTS 0 0 0 0 0 0 0 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
j. NFP-CMM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0 0 0 0 0 0 0 0
• Non-NHTS 0 0 0 0 0 0 0 0 0
k. NFP-STM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0 0 0 0 0 0 0 0
• Non-NHTS 0 0 0 0 0 0 0 0 0
l. NFP-SDM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0 0 0 0 0 0 0 0
• Non-NHTS 0 0 0 0 0 0 0 0 0
m. Total Current Users 0 0 0 0 0 0 0 0 0
• NHTS 0 0 0 0 0 0 0 0 0
• Non-NHTS 0 0 0 0 0 0 0 0 0
Section B. Maternal Care
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
1. No. of pregnant women w/
at least 4 prenatal check-
ups - Total 0 1 0 1
• NHTS 0 0 0 0
• Non-NHTS 0 1 0 1
2. No. of pregnant women
assessed of their nutritional
status during the 1st tri. -Total 0 1 0 1
• NHTS 0 0 0 0
• Non-NHTS 0 1 0 1
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
c. No. of pregnant women
seen in the first trimester
who have high BMI - Total 0 0 0 0
• NHTS 0 0 0 0
• Non-NHTS 0 0 0 0
3. No. of pregnant women for
the first time given 2 doses of
Td vaccination - Total 0 1 0 1
• NHTS 0 0 0 0
• Non-NHTS 0 1 0 1
4. No. of pregnant women for
the 2nd or more times given
at least 3 doses of Td
vaccination (Td2 Plus) - Total
0 0 0 0
• NHTS 0 0 0 0
• Non-NHTS 0 0 0 0
5. No. of pregnant women who
completed the dose of iron
with folic acid
supplementation - Total 0 1 0 1
 • NHTS 0 0 0 0
• Non-NHTS 0 1 0 1
6. No. of pregnant women who
completed doses of calcium
carbonate supplementation -
Total 0 0 0 0
• NHTS 0 0 0 0
• Non-NHTS 0 0 0 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
12. No. of pregnant women
tested positive for Hepatitis
B - Total 0 0 0 0
• NHTS 0 0 0 0
• Non-NHTS 0 0 0 0
13. No. of pregnant women
screened for HIV - Total 0 0 0 0
• NHTS 0 0 0 0
• Non-NHTS 0 0 0 0
14. No. of pregnant women
tested for CBC or Hgb&Hct
count - Total 0 1 0 1
• NHTS 0 0 0 0
• Non-NHTS 0 1 0 1
15. No. of pregnant women
tested for CBC or Hgb&Hct
count diagnosed with
anemia - Total 0 0 0 0
• NHTS 0 0 0 0
• Non-NHTS 0 0 0 0
16. No. of pregnant women
screened for gestational
diabetes – Total 0 0 0 0
• NHTS 0 0 0 0
• Non-NHTS 0 0 0 0
17.   No. of pregnant women
tested positive for
gestational diabetes – Total 0 0 0 0
• NHTS 0 0 0 0
• Non-NHTS 0 0 0 0
Indicators Age Total Remarks
(Col 3)  (Col. 4)
 Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
a. No. of deliveries attended
by a doctor - Total 0 0 0 0
• NHTS 0 0 0 0
• Non-NHTS 0 0 0 0
b. No. of deliveries attended
by a nurse – Total 0 0 0 0
• NHTS 0 0 0 0
• Non-NHTS 0 0 0 0
c. No. of deliveries attended
by midwives - Total 0 1 0 1
• NHTS 0 0 0 0
• Non-NHTS 0 1 0 1
22. No. of deliveries attended by
non-skilled health
professionals - Total 0 0 0 0
• NHTS 0 0 0 0
• Non-NHTS 0 0 0 0
a. No. of deliveries attended
by Hilot/TBA - Total 0 0 0 0
• NHTS 0 0 0 0
• Non-NHTS 0 0 0 0
b. No. of deliveries attended
by others - Total 0 0 0 0
• NHTS 0 0 0 0
• Non-NHTS 0 0 0 0
23. No. of health facility-based
deliveries - Total 0 0 0 0
• NHTS 0 0 0 0
• Non-NHTS 0 0 0 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
27c. No. of fetal deaths - Total

0 0 0 0
• NHTS 0 0 0 0
• Non-NHTS 0 0 0 0
27d. No. of abortion/
miscarriage - Total
0 0 0 0
• NHTS 0 0 0 0
• Non-NHTS 0 0 0 0

Section C. Child Care a

Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
C1. Immunization Services
1. CPAB - Total 0 1 1 6. DPT-HiB-HepB 3 - Total
• NHTS 0 0 0 • NHTS
• Non-NHTS 0 1 1 • Non-NHTS
2. BCG - Total 0 1 1 7. OPV 1 - Total
• NHTS 0 0 0 • NHTS
• Non-NHTS 0 1 1 • Non-NHTS
3. HepB, within 24 hours. - Total 0 1 1 8. OPV 2 - Total
• NHTS 0 0 0 • NHTS
• Non-NHTS 0 1 1 • Non-NHTS
4. DPT-HiB-HepB 1 - Total 0 0 0 9. OPV 3 - Total
• NHTS 0 0 0 • NHTS
• Non-NHTS 0 0 0 • Non-NHTS
5. DPT-HiB-HepB 2 - Total 0 0 0 10. IPV - Total
• NHTS 0 0 0 • NHTS
• Non-NHTS 0 0 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
16. FIC - Total 0 0 0 18. Td, Grade 1 (November) - Total
• NHTS 0 0 0 • NHTS
• Non-NHTS 0 0 0 • Non-NHTS
17. CIC - Total 0 0 0 19. MR, Grade 1 (November) - Total
• NHTS 0 0 0 • NHTS
• Non-NHTS 0 0 0 • Non-NHTS
C2. Nutrition Services
22. Newborns initiated on breastfeeding
immediately after birth lasting to 90 mins - 28. Infants 6-11 mos. old seen - Total
Total 0 1 1
• NHTS 0 0 0 • NHTS
• Non-NHTS 0 1 1 • Non-NHTS
23. Preterm/LBW infants given iron 29. Infants 6-11 mos. given 1 dose of
supplementation - Total 0 0 0 Vitamin A 100,000 I.U. - Total
• NHTS 0 0 0 • NHTS
• Non-NHTS 0 0 0 • Non-NHTS
24. Infants 6 mos. old seen - Total 1 0 1 30. Children 12-59 mos seen - Total
• NHTS 0 0 0 • NHTS
• Non-NHTS 1 0 1 • Non-NHTS
25. Infants exclusively breastfed until 6th month - 31. Children 12-59 mos. old given 2
Total 1 0 1 doses of Vitamin A 200,000 I.U. - Total
• NHTS 0 0 0 • NHTS
• Non-NHTS 1 0 1 • Non-NHTS
26. Infants 6 mos. old initiated to complementary 32. Infant 6-11 months old who completed
feeding with continued breastfeeding - Total 1 0 1 MNP supplementation - Total
• NHTS 0 0 0 • NHTS
• Non-NHTS 1 0 1 • Non-NHTS
27. Infants 6 mos. old initiated to complementary
feeding but no longer or never been breastfed 33. Children 12-23 mos. seen - Total
- Total 1 0 1
• NHTS 0 0 0 • NHTS
• Non-NHTS 1 0 1 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
0
40. 1-19 y/o given 2 doses of deworming drug - 42. SAC, 5-9 y/o dewormed (2 doses) -
Total 0 0 0 Total
• NHTS 0 0 0 • NHTS
• Non-NHTS 0 0 0 • Non-NHTS
41. PSAC, 1-4 y/o dewormed (2 doses) - Total 0 0 0
• NHTS 0 0 0
• Non-NHTS 0 0 0
0
44. Sick Infants 6-11 mos. old seen - Total 47. Sick Children 12-59 mos. old
0 0 0 received Vitamin A - Total
• NHTS 0 0 0 • NHTS
• Non-NHTS 0 0 0 • Non-NHTS
45. Sick Infants 6-11 mos. old received 48. Diarrhea cases 0-59 months old seen
Vitamin A - Total 0 0 0 - Total
• NHTS 0 0 0 • NHTS
• Non-NHTS 0 0 0 • Non-NHTS
49. Diarrhea cases 0-59 months old
46. Sick Children 12-59 mos. old seen - Total
0 0 0 received ORS - Total
• NHTS 0 0 0 • NHTS
• Non-NHTS 0 0 0 • Non-NHTS
 To be submitted Qua
Section E. Infectious Disease Preven
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
E1. Filariasis Prevention and Control E2. Schistosomiasis Prevention and Contro
1. No. of individual examined for lymphatic 1. No. of people 5-65 y/o who ingested
filariasis - Total 0 0 0 MDA drugs - Total
2. No. of individual examined found positive for 2. No. of patients seen - Total
lymphatic filariasis - Total 0 0 0 3. No. of suspected cases seen
3. No. of lymphatic filariasis cases examined with 4. No. acute clinically diagnosed cases -
manifestation of either lymphedema,hydrocele, Total
elephantiasis - Total
0 0 0 5. No. of confirmed acute cases - Total
6. No. of chronic clinically diagnosed
cases - Total
Section F. _________________________
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
URTI 8 9 17
ARI 6 10 16
HPN 28 25 53
DIABETES 4 10 14
INFECTED WOUND 3 2 6
 ___MAY_____ YEAR: ____2022___

M1
TONG
NTONG
G CITY

BRGY
S ORIENTAL

r submission to RHU/MHC

Services and Deworming for Women of Reproductive Age

Total A3. Deworming Services SES Total

Col. 3) (Col. 1) (Col. 2) (Col. 3)

NHTS Non-NHTS
1. No. of women 20-49 years old given 2 doses of
15 deworming drugs - Total
0 0 0
15
0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19

0 0 0 0 0 0 0 0 0 4 4 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 4 4 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 2 2 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 2 2 0 0
0 0 0 0 0 0 0 0 0 45 45 0 0
0 0 0 0 0 0 0 0 0 7 7 0 0
0 0 0 0 0 0 0 0 0 38 38 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
 0 0 0 0 0 0 0 0 2 0 2 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 45 45 0 0
0 0 0 0 0 0 0 0 0 7 7 0 0
0 0 0 0 0 0 0 0 0 38 38 0 0

0 0 0 0 0 0 0 0 0 14 14 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 14 14 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 2 3 5 0 1
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 2 3 5 0 1
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
on B. Maternal Care and Services
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

a. Number of pregnant women seen in the

first trimester who have normal BMI -
Total 0 1 0 1
• NHTS 0 0 0 0
• Non-NHTS 0 1 0 1
b. No. of pregnant women seen in the first
trimester who have low BMI - Total
0 0 0 0
• NHTS 0 0 0 0
• Non-NHTS 0 0 0 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

7. No. of pregnant women given iodine

capsules – Total
0 0 0 0
• NHTS 0 0 0 0
• Non-NHTS 0 0 0 0
8. No. of pregnant women given one dose
of deworming tablet - Total
0 0 0 0
• NHTS 0 0 0 0
• Non-NHTS 0 0 0 0
9. No. of pregnant women screened for
syphilis - Total

0 0 0 0
• NHTS 0 0 0 0
• Non-NHTS 0 0 0 0
10. No. of pregnant women tested positive
for syphilis - Total

0 0 0 0
 • NHTS 0 0 0 0
• Non-NHTS 0 0 0 0
11. No. of pregnant women screened for
Hepatitis B - Total

0 0 0 0
• NHTS 0 0 0 0
• Non-NHTS 0 0 0 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
18. No. of deliveries – Total

0 1 0 1
• NHTS 0 0 0 0
• Non-NHTS 0 1 0 1
19. No. of live births – Total
0 1 0 1
• NHTS 0 0 0 0
• Non-NHTS 0 1 0 1
20a. No. of live births with normal birth
weight - Total
0 1 0 1
• NHTS 0 0 0 0
• Non-NHTS 0 1 0 1
20b. No. of live births with low birth weight
- Total

0 0 0 0
• NHTS 0 0 0 0
• Non-NHTS 0 0 0 0
20c. No. of live births with unknown birth
weight- Total
0 0 0 0
• NHTS 0 0 0 0
• Non-NHTS 0 0 0 0
21. No. of deliveries attended by skilled
health professionals - Total
0 1 0 1
• NHTS 0 0 0 0
• Non-NHTS 0 1 0 1
rks Indicators Age Total Remarks
4) (Col 3)  (Col. 4)
rks Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

24a. No. of deliveries in public health

facility - Total 0 0 0 0
• NHTS 0 0 0 0
• Non-NHTS 0 0 0 0
24b. No. of deliveries in private health
facility - Total 0 0 0 0
• NHTS 0 0 0 0
• Non-NHTS 0 0 0 0
25. No. of non-facility-based deliveries -
Total 0 1 0 1
• NHTS 0 0 0 0
• Non-NHTS 0 1 0 1
26a. No. of vaginal deliveries – Total

0 1 0 1
• NHTS 0 0 0 0
• Non-NHTS 0 1 0 1
26b. No. of deliveries by cesarean
section – Total 0 0 0 0
• NHTS 0 0 0 0
• Non-NHTS 0 0 0 0
27a. No. of full-term births – Total
0 1 0 1
• NHTS 0 0 0 0
• Non-NHTS 0 1 0 1
27b. No. of pre-term births – Total
0 0 0 0
• NHTS 0 0 0 0
• Non-NHTS 0 0 0 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B3. Postpartum and Newborn Care
28. No. of postpartum women together
with their newborn who completed at
least 2 postpartum check-ups - Total
0 1 0 1
• NHTS 0 0 0 0
• Non-NHTS 0 1 0 1
 29. No. of postpartum women who
completed iron with folic acid
supplementation - Total 0 1 0 1
• NHTS 0 0 0 0
• Non-NHTS 0 1 0 1
30. No. of postpartum women with
Vitamin A supplementation – Total 0 0 0 0
• NHTS 0 0 0 0
• Non-NHTS 0 0 0 0
ction C. Child Care and Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)

epB 3 - Total 0 0 0 11. PCV 1 - Total 0 0

0 0 0 • NHTS 0 0
TS 0 0 0 • Non-NHTS 0 0
al 0 0 0 12. PCV 2 - Total 0 0
0 0 0 • NHTS 0 0
TS 0 0 0 • Non-NHTS 0 0
al 0 0 0 13. PCV 3 - Total 0 0
0 0 0 • NHTS 0 0
TS 0 0 0 • Non-NHTS 0 0
al 0 0 0 14. MMR 1 - Total 0 0
0 0 0 • NHTS 0 0
TS 0 0 0 • Non-NHTS 0 0
0 0 0 15. MMR 2 - Total 0 0
0 0 0 • NHTS 0 0
TS 0 0 0 • Non-NHTS 0 0
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
1 (November) - Total 0 0 0 20. Td, Grade 7 (November) - Total 0 0
0 0 0 • NHTS 0 0
TS 0 0 0 • Non-NHTS 0 0
e 1 (November) - Total 0 0 0 21. MR, Grade 7 (November) - Total 0 0
0 0 0 • NHTS 0 0
TS 0 0 0 • Non-NHTS 0 0

34. Children 12-23 mos. who completed

1 mos. old seen - Total
MNP supplementation - Total
0 0 0 0 0
0 0 0 • NHTS 0 0
TS 0 0 0 • Non-NHTS 0 0
 1 mos. given 1 dose of
35. Children 0-59 mos. seen - Total
100,000 I.U. - Total 0 0 0 0 0
0 0 0 • NHTS 0 0
TS 0 0 0 • Non-NHTS 0 0
2-59 mos seen - Total 0 0 0 36. Stunted - Total 0 0
0 0 0 • NHTS 0 0
TS 0 0 0 • Non-NHTS 0 0
2-59 mos. old given 2
37. Wasted - Total
tamin A 200,000 I.U. - Total 0 0 0 0 0
0 0 0 • NHTS 0 0
TS 0 0 0 • Non-NHTS 0 0
1 months old who completed
38. Overweight/Obese - Total
lementation - Total 0 0 0 0 0
0 0 0 • NHTS 0 0
TS 0 0 0 • Non-NHTS 0 0

2-23 mos. seen - Total 39. Normal - Total

0 0 0 0 0
0 0 0 • NHTS 0 0
TS 0 0 0 • Non-NHTS 0 0
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col. 1) (Col 2) (Col 3)

y/o dewormed (2 doses) - 43. Adolescents, 10-19 y/o dewormed

0 0 0 (2 doses) - Total 0 0
0 0 0 • NHTS 0 0
TS 0 0 0 • Non-NHTS 0 0

ren 12-59 mos. old 50. Diarrhea cases 0-59 mos. received
itamin A - Total 0 0 0 ORS w/ zinc - Total 0 0
0 0 0 • NHTS 0 0
TS 0 0 0 • Non-NHTS 0 0
ases 0-59 months old seen 51. Pneumonia cases 0-59 mos. old
0 0 0 seen - Total 0 0
0 0 0 • NHTS 0 0
TS 0 0 0 • Non-NHTS 0 0
ases 0-59 months old 52. Pneumonia cases 0-59 mos. old
ORS - Total 0 0 0 completed treatment - Total 0 0
0 0 0 • NHTS 0 0
TS 0 0 0 • Non-NHTS 0 0
 To be submitted Quarterly
ous Disease Prevention and Control Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
miasis Prevention and Control E2. Schistosomiasis Prevention and Control (Con't.)
le 5-65 y/o who ingested 7. No. confirmed chronic cases - Total
- Total 0 0 0 0 0
nts seen - Total 0 0 0 8. No. of confirmed cases (acute and
ected cases seen 0 0 0 chronic) - Total 0 0
nically diagnosed cases - 9. No. of cases treated - Total
0 0 0 0 0
rmed acute cases - Total 0 0 0 10. No. of confirmed chronic cases
nic clinically diagnosed referred to a hospital facility - Total
al 0 0 0 0 0
_________________________________________
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
M1
RGY
Total

(Col. 3)

New Acceptors
(Present Month)

(Col. 7)
20-49 Total

0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
 0 0
0 0
0 0
0 0
0 0
0 0

0 0
0 0
0 0
0 0
0 0
0 0

0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 1
0 0
0 1
0 0
0 0
0 0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
 0 0
0 0
0 0

Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
 Total
(Col 4)

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Total
(Col 4)
0
0
0
0
0
0

0
0
0
 0
0
0
0
0
0

0
0
0

0
0
0

0
0
0
Total
(Col 4)

0
0
0

0
0
0

0
0
0

0
0
0
 Total
(Col 4)
't.)

Total
(Col 4)
 FHSIS REPORT for the MONTH: ___JANUARY_____
Name of Barangay: _____TAGPAKO_________
Name of BHS: _______________________
Name of Municipality/City: _______________________
Name of Province: ________________________
Projected Population of the Year: _______________________
For submission to RHU/MHC

Section A. Family Planning Services and Dewor

A1. Modern FP Unmet Need Age Total

(Col. 1) (Col. 2) (Col. 3)

10-14 15-19 20-49
1. No. of WRA with unmet
need for modern FP - Total 5 5 5
15
• NHTS 5 5 5 15
• Non-NHTS 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
a. Female Sterilization/ BTL - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
b. Male Sterilization/ NSV-Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
c. Condom - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d. Pills - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
 d.1 Pills-POP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d.2 Pills-COC - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
e. Injectables (DMPA/ POI) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
f. Implant - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g. IUD (IUD-I and IUD-PP) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.1 IUD-I- Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.2 IUD-PP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
h. NFP-LAM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
i. NFP-BBT - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
j. NFP-CMM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
k. NFP-STM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
l. NFP-SDM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
m. Total Current Users 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
Section B. Maternal Care
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
1. No. of pregnant women w/
at least 4 prenatal check-
ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
2. No. of pregnant women
assessed of their nutritional
status during the 1st tri. -Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
c. No. of pregnant women
seen in the first trimester
who have high BMI - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
3. No. of pregnant women for
the first time given 2 doses of
Td vaccination - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
4. No. of pregnant women for
the 2nd or more times given
at least 3 doses of Td
vaccination (Td2 Plus) - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
5. No. of pregnant women who
completed the dose of iron
with folic acid
supplementation - Total 0 0 0 0
 • NHTS 0
• Non-NHTS 0
6. No. of pregnant women who
completed doses of calcium
carbonate supplementation -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
12. No. of pregnant women
tested positive for Hepatitis
B - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
13. No. of pregnant women
screened for HIV - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
14. No. of pregnant women
tested for CBC or Hgb&Hct
count - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
15. No. of pregnant women
tested for CBC or Hgb&Hct
count diagnosed with
anemia - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
16. No. of pregnant women
screened for gestational
diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
17.   No. of pregnant women
tested positive for
gestational diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col 3)  (Col. 4)
 Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
a. No. of deliveries attended
by a doctor - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by a nurse – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
c. No. of deliveries attended
by midwives - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
22. No. of deliveries attended by
non-skilled health
professionals - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
a. No. of deliveries attended
by Hilot/TBA - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by others - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
23. No. of health facility-based
deliveries - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
27c. No. of fetal deaths - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
27d. No. of abortion/
miscarriage - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0

Section C. Child Care a

Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
C1. Immunization Services
1. CPAB - Total 0 0 0 6. DPT-HiB-HepB 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
2. BCG - Total 0 0 0 7. OPV 1 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
3. HepB, within 24 hours. - Total 0 0 0 8. OPV 2 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
4. DPT-HiB-HepB 1 - Total 0 0 0 9. OPV 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
5. DPT-HiB-HepB 2 - Total 0 0 0 10. IPV - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
16. FIC - Total 0 0 0 18. Td, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
17. CIC - Total 0 0 0 19. MR, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
C2. Nutrition Services
22. Newborns initiated on breastfeeding
immediately after birth lasting to 90 mins - 28. Infants 6-11 mos. old seen - Total
Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
23. Preterm/LBW infants given iron 29. Infants 6-11 mos. given 1 dose of
supplementation - Total 0 0 0 Vitamin A 100,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
24. Infants 6 mos. old seen - Total 0 0 0 30. Children 12-59 mos seen - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
25. Infants exclusively breastfed until 6th month - 31. Children 12-59 mos. old given 2
Total 0 0 0 doses of Vitamin A 200,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
26. Infants 6 mos. old initiated to complementary 32. Infant 6-11 months old who completed
feeding with continued breastfeeding - Total 0 0 0 MNP supplementation - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
27. Infants 6 mos. old initiated to complementary
feeding but no longer or never been breastfed 33. Children 12-23 mos. seen - Total
- Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
0
40. 1-19 y/o given 2 doses of deworming drug - 42. SAC, 5-9 y/o dewormed (2 doses) -
Total 0 0 0 Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
41. PSAC, 1-4 y/o dewormed (2 doses) - Total 0 0 0
• NHTS 0
• Non-NHTS 0
0
44. Sick Infants 6-11 mos. old seen - Total 47. Sick Children 12-59 mos. old
0 0 0 received Vitamin A - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
45. Sick Infants 6-11 mos. old received 48. Diarrhea cases 0-59 months old seen
Vitamin A - Total 0 0 0 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
49. Diarrhea cases 0-59 months old
46. Sick Children 12-59 mos. old seen - Total
0 0 0 received ORS - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
 To be submitted Qua
Section E. Infectious Disease Preven
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
E1. Filariasis Prevention and Control E2. Schistosomiasis Prevention and Contro
1. No. of individual examined for lymphatic 1. No. of people 5-65 y/o who ingested
filariasis - Total 0 MDA drugs - Total
2. No. of individual examined found positive for 2. No. of patients seen - Total
lymphatic filariasis - Total 0 3. No. of suspected cases seen
3. No. of lymphatic filariasis cases examined with 4. No. acute clinically diagnosed cases -
manifestation of either lymphedema,hydrocele, Total
elephantiasis - Total
0 5. No. of confirmed acute cases - Total
6. No. of chronic clinically diagnosed
cases - Total
Section F. _________________________
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
 ___JANUARY_____ YEAR: ____2020___

M1
AGPAKO__________________________
_________________________
_________________________

BRGY
________________________
________________________
r submission to RHU/MHC

Services and Deworming for Women of Reproductive Age

Total A3. Deworming Services SES Total

Col. 3) (Col. 1) (Col. 2) (Col. 3)

NHTS Non-NHTS
1. No. of women 20-49 years old given 2 doses of
15 deworming drugs - Total
0 0 0
15
0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
on B. Maternal Care and Services
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

a. Number of pregnant women seen in the

first trimester who have normal BMI -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of pregnant women seen in the first
trimester who have low BMI - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

7. No. of pregnant women given iodine

capsules – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
8. No. of pregnant women given one dose
of deworming tablet - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
9. No. of pregnant women screened for
syphilis - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
10. No. of pregnant women tested positive
for syphilis - Total

0 0 0 0
 • NHTS 0
• Non-NHTS 0
11. No. of pregnant women screened for
Hepatitis B - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
18. No. of deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
19. No. of live births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20a. No. of live births with normal birth
weight - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20b. No. of live births with low birth weight
- Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
20c. No. of live births with unknown birth
weight- Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
21. No. of deliveries attended by skilled
health professionals - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col 3)  (Col. 4)
rks Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

24a. No. of deliveries in public health

facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
24b. No. of deliveries in private health
facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
25. No. of non-facility-based deliveries -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
26a. No. of vaginal deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
26b. No. of deliveries by cesarean
section – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
27a. No. of full-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
27b. No. of pre-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B3. Postpartum and Newborn Care
28. No. of postpartum women together
with their newborn who completed at
least 2 postpartum check-ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
 29. No. of postpartum women who
completed iron with folic acid
supplementation - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
30. No. of postpartum women with
Vitamin A supplementation – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
ction C. Child Care and Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)

epB 3 - Total 0 0 0 11. PCV 1 - Total 0 0

0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 12. PCV 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 13. PCV 3 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 14. MMR 1 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
0 0 0 15. MMR 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
1 (November) - Total 0 0 0 20. Td, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
e 1 (November) - Total 0 0 0 21. MR, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

34. Children 12-23 mos. who completed

1 mos. old seen - Total
MNP supplementation - Total
0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
 1 mos. given 1 dose of
35. Children 0-59 mos. seen - Total
100,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos seen - Total 0 0 0 36. Stunted - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos. old given 2
37. Wasted - Total
tamin A 200,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
1 months old who completed
38. Overweight/Obese - Total
lementation - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS

2-23 mos. seen - Total 39. Normal - Total

0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col. 1) (Col 2) (Col 3)

y/o dewormed (2 doses) - 43. Adolescents, 10-19 y/o dewormed

0 0 0 (2 doses) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

ren 12-59 mos. old 50. Diarrhea cases 0-59 mos. received
itamin A - Total 0 0 0 ORS w/ zinc - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old seen 51. Pneumonia cases 0-59 mos. old
0 0 0 seen - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old 52. Pneumonia cases 0-59 mos. old
ORS - Total 0 0 0 completed treatment - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
 To be submitted Quarterly
ous Disease Prevention and Control Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
miasis Prevention and Control E2. Schistosomiasis Prevention and Control (Con't.)
le 5-65 y/o who ingested 7. No. confirmed chronic cases - Total
- Total 0
nts seen - Total 0 8. No. of confirmed cases (acute and
ected cases seen 0 chronic) - Total
clinically diagnosed cases - 9. No. of cases treated - Total
0
rmed acute cases - Total 0 10. No. of confirmed chronic cases
nic clinically diagnosed referred to a hospital facility - Total
al 0
_________________________________________
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
M1
RGY
Total

(Col. 3)

New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
 0 0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0 0
0
0
0 0
0
0
0 0
0
0
 0 0
0
0

Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
 Total
(Col 4)

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Total
(Col 4)
0
0
0
0
0
0

0
0
0
 0
0
0
0
0
0

0
0
0

0
0
0

0
0
0
Total
(Col 4)

0
0
0

0
0
0

0
0
0

0
0
0
 Total
(Col 4)
't.)

Total
(Col 4)
 FHSIS REPORT for the MONTH: ___JANUARY_____
Name of Barangay: _____TAGPAKO_________
Name of BHS: _______________________
Name of Municipality/City: _______________________
Name of Province: ________________________
Projected Population of the Year: _______________________
For submission to RHU/MHC

Section A. Family Planning Services and Dewor

A1. Modern FP Unmet Need Age Total

(Col. 1) (Col. 2) (Col. 3)

10-14 15-19 20-49
1. No. of WRA with unmet
need for modern FP - Total 5 5 5
15
• NHTS 5 5 5 15
• Non-NHTS 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
a. Female Sterilization/ BTL - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
b. Male Sterilization/ NSV-Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
c. Condom - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d. Pills - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
 d.1 Pills-POP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d.2 Pills-COC - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
e. Injectables (DMPA/ POI) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
f. Implant - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g. IUD (IUD-I and IUD-PP) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.1 IUD-I- Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.2 IUD-PP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
h. NFP-LAM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
i. NFP-BBT - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
j. NFP-CMM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
k. NFP-STM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
l. NFP-SDM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
m. Total Current Users 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
Section B. Maternal Care
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
1. No. of pregnant women w/
at least 4 prenatal check-
ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
2. No. of pregnant women
assessed of their nutritional
status during the 1st tri. -Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
c. No. of pregnant women
seen in the first trimester
who have high BMI - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
3. No. of pregnant women for
the first time given 2 doses of
Td vaccination - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
4. No. of pregnant women for
the 2nd or more times given
at least 3 doses of Td
vaccination (Td2 Plus) - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
5. No. of pregnant women who
completed the dose of iron
with folic acid
supplementation - Total 0 0 0 0
 • NHTS 0
• Non-NHTS 0
6. No. of pregnant women who
completed doses of calcium
carbonate supplementation -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
12. No. of pregnant women
tested positive for Hepatitis
B - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
13. No. of pregnant women
screened for HIV - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
14. No. of pregnant women
tested for CBC or Hgb&Hct
count - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
15. No. of pregnant women
tested for CBC or Hgb&Hct
count diagnosed with
anemia - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
16. No. of pregnant women
screened for gestational
diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
17.   No. of pregnant women
tested positive for
gestational diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col 3)  (Col. 4)
 Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
a. No. of deliveries attended
by a doctor - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by a nurse – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
c. No. of deliveries attended
by midwives - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
22. No. of deliveries attended by
non-skilled health
professionals - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
a. No. of deliveries attended
by Hilot/TBA - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by others - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
23. No. of health facility-based
deliveries - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
27c. No. of fetal deaths - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
27d. No. of abortion/
miscarriage - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0

Section C. Child Care a

Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
C1. Immunization Services
1. CPAB - Total 0 0 0 6. DPT-HiB-HepB 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
2. BCG - Total 0 0 0 7. OPV 1 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
3. HepB, within 24 hours. - Total 0 0 0 8. OPV 2 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
4. DPT-HiB-HepB 1 - Total 0 0 0 9. OPV 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
5. DPT-HiB-HepB 2 - Total 0 0 0 10. IPV - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
16. FIC - Total 0 0 0 18. Td, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
17. CIC - Total 0 0 0 19. MR, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
C2. Nutrition Services
22. Newborns initiated on breastfeeding
immediately after birth lasting to 90 mins - 28. Infants 6-11 mos. old seen - Total
Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
23. Preterm/LBW infants given iron 29. Infants 6-11 mos. given 1 dose of
supplementation - Total 0 0 0 Vitamin A 100,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
24. Infants 6 mos. old seen - Total 0 0 0 30. Children 12-59 mos seen - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
25. Infants exclusively breastfed until 6th month - 31. Children 12-59 mos. old given 2
Total 0 0 0 doses of Vitamin A 200,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
26. Infants 6 mos. old initiated to complementary 32. Infant 6-11 months old who completed
feeding with continued breastfeeding - Total 0 0 0 MNP supplementation - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
27. Infants 6 mos. old initiated to complementary
feeding but no longer or never been breastfed 33. Children 12-23 mos. seen - Total
- Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
0
40. 1-19 y/o given 2 doses of deworming drug - 42. SAC, 5-9 y/o dewormed (2 doses) -
Total 0 0 0 Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
41. PSAC, 1-4 y/o dewormed (2 doses) - Total 0 0 0
• NHTS 0
• Non-NHTS 0
0
44. Sick Infants 6-11 mos. old seen - Total 47. Sick Children 12-59 mos. old
0 0 0 received Vitamin A - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
45. Sick Infants 6-11 mos. old received 48. Diarrhea cases 0-59 months old seen
Vitamin A - Total 0 0 0 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
49. Diarrhea cases 0-59 months old
46. Sick Children 12-59 mos. old seen - Total
0 0 0 received ORS - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
 To be submitted Qua
Section E. Infectious Disease Preven
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
E1. Filariasis Prevention and Control E2. Schistosomiasis Prevention and Contro
1. No. of individual examined for lymphatic 1. No. of people 5-65 y/o who ingested
filariasis - Total 0 MDA drugs - Total
2. No. of individual examined found positive for 2. No. of patients seen - Total
lymphatic filariasis - Total 0 3. No. of suspected cases seen
3. No. of lymphatic filariasis cases examined with 4. No. acute clinically diagnosed cases -
manifestation of either lymphedema,hydrocele, Total
elephantiasis - Total
0 5. No. of confirmed acute cases - Total
6. No. of chronic clinically diagnosed
cases - Total
Section F. _________________________
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
 ___JANUARY_____ YEAR: ____2020___

M1
AGPAKO__________________________
_________________________
_________________________

BRGY
________________________
________________________
r submission to RHU/MHC

Services and Deworming for Women of Reproductive Age

Total A3. Deworming Services SES Total

Col. 3) (Col. 1) (Col. 2) (Col. 3)

NHTS Non-NHTS
1. No. of women 20-49 years old given 2 doses of
15 deworming drugs - Total
0 0 0
15
0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
on B. Maternal Care and Services
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

a. Number of pregnant women seen in the

first trimester who have normal BMI -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of pregnant women seen in the first
trimester who have low BMI - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

7. No. of pregnant women given iodine

capsules – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
8. No. of pregnant women given one dose
of deworming tablet - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
9. No. of pregnant women screened for
syphilis - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
10. No. of pregnant women tested positive
for syphilis - Total

0 0 0 0
 • NHTS 0
• Non-NHTS 0
11. No. of pregnant women screened for
Hepatitis B - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
18. No. of deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
19. No. of live births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20a. No. of live births with normal birth
weight - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20b. No. of live births with low birth weight
- Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
20c. No. of live births with unknown birth
weight- Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
21. No. of deliveries attended by skilled
health professionals - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col 3)  (Col. 4)
rks Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

24a. No. of deliveries in public health

facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
24b. No. of deliveries in private health
facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
25. No. of non-facility-based deliveries -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
26a. No. of vaginal deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
26b. No. of deliveries by cesarean
section – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
27a. No. of full-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
27b. No. of pre-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B3. Postpartum and Newborn Care
28. No. of postpartum women together
with their newborn who completed at
least 2 postpartum check-ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
 29. No. of postpartum women who
completed iron with folic acid
supplementation - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
30. No. of postpartum women with
Vitamin A supplementation – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
ction C. Child Care and Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)

epB 3 - Total 0 0 0 11. PCV 1 - Total 0 0

0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 12. PCV 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 13. PCV 3 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 14. MMR 1 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
0 0 0 15. MMR 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
1 (November) - Total 0 0 0 20. Td, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
e 1 (November) - Total 0 0 0 21. MR, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

34. Children 12-23 mos. who completed

1 mos. old seen - Total
MNP supplementation - Total
0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
 1 mos. given 1 dose of
35. Children 0-59 mos. seen - Total
100,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos seen - Total 0 0 0 36. Stunted - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos. old given 2
37. Wasted - Total
tamin A 200,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
1 months old who completed
38. Overweight/Obese - Total
lementation - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS

2-23 mos. seen - Total 39. Normal - Total

0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col. 1) (Col 2) (Col 3)

y/o dewormed (2 doses) - 43. Adolescents, 10-19 y/o dewormed

0 0 0 (2 doses) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

ren 12-59 mos. old 50. Diarrhea cases 0-59 mos. received
itamin A - Total 0 0 0 ORS w/ zinc - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old seen 51. Pneumonia cases 0-59 mos. old
0 0 0 seen - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old 52. Pneumonia cases 0-59 mos. old
ORS - Total 0 0 0 completed treatment - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
 To be submitted Quarterly
ous Disease Prevention and Control Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
miasis Prevention and Control E2. Schistosomiasis Prevention and Control (Con't.)
le 5-65 y/o who ingested 7. No. confirmed chronic cases - Total
- Total 0
nts seen - Total 0 8. No. of confirmed cases (acute and
ected cases seen 0 chronic) - Total
clinically diagnosed cases - 9. No. of cases treated - Total
0
rmed acute cases - Total 0 10. No. of confirmed chronic cases
nic clinically diagnosed referred to a hospital facility - Total
al 0
_________________________________________
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
M1
RGY
Total

(Col. 3)

New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
 0 0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0 0
0
0
0 0
0
0
0 0
0
0
 0 0
0
0

Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
 Total
(Col 4)

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Total
(Col 4)
0
0
0
0
0
0

0
0
0
 0
0
0
0
0
0

0
0
0

0
0
0

0
0
0
Total
(Col 4)

0
0
0

0
0
0

0
0
0

0
0
0
 Total
(Col 4)
't.)

Total
(Col 4)
 FHSIS REPORT for the MONTH: ___JANUARY_____
Name of Barangay: _____TAGPAKO_________
Name of BHS: _______________________
Name of Municipality/City: _______________________
Name of Province: ________________________
Projected Population of the Year: _______________________
For submission to RHU/MHC

Section A. Family Planning Services and Dewor

A1. Modern FP Unmet Need Age Total

(Col. 1) (Col. 2) (Col. 3)

10-14 15-19 20-49
1. No. of WRA with unmet
need for modern FP - Total 5 5 5
15
• NHTS 5 5 5 15
• Non-NHTS 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
a. Female Sterilization/ BTL - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
b. Male Sterilization/ NSV-Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
c. Condom - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d. Pills - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
 d.1 Pills-POP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d.2 Pills-COC - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
e. Injectables (DMPA/ POI) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
f. Implant - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g. IUD (IUD-I and IUD-PP) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.1 IUD-I- Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.2 IUD-PP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
h. NFP-LAM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
i. NFP-BBT - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
j. NFP-CMM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
k. NFP-STM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
l. NFP-SDM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
m. Total Current Users 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
Section B. Maternal Care
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
1. No. of pregnant women w/
at least 4 prenatal check-
ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
2. No. of pregnant women
assessed of their nutritional
status during the 1st tri. -Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
c. No. of pregnant women
seen in the first trimester
who have high BMI - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
3. No. of pregnant women for
the first time given 2 doses of
Td vaccination - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
4. No. of pregnant women for
the 2nd or more times given
at least 3 doses of Td
vaccination (Td2 Plus) - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
5. No. of pregnant women who
completed the dose of iron
with folic acid
supplementation - Total 0 0 0 0
 • NHTS 0
• Non-NHTS 0
6. No. of pregnant women who
completed doses of calcium
carbonate supplementation -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
12. No. of pregnant women
tested positive for Hepatitis
B - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
13. No. of pregnant women
screened for HIV - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
14. No. of pregnant women
tested for CBC or Hgb&Hct
count - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
15. No. of pregnant women
tested for CBC or Hgb&Hct
count diagnosed with
anemia - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
16. No. of pregnant women
screened for gestational
diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
17.   No. of pregnant women
tested positive for
gestational diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col 3)  (Col. 4)
 Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
a. No. of deliveries attended
by a doctor - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by a nurse – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
c. No. of deliveries attended
by midwives - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
22. No. of deliveries attended by
non-skilled health
professionals - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
a. No. of deliveries attended
by Hilot/TBA - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by others - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
23. No. of health facility-based
deliveries - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
27c. No. of fetal deaths - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
27d. No. of abortion/
miscarriage - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0

Section C. Child Care a

Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
C1. Immunization Services
1. CPAB - Total 0 0 0 6. DPT-HiB-HepB 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
2. BCG - Total 0 0 0 7. OPV 1 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
3. HepB, within 24 hours. - Total 0 0 0 8. OPV 2 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
4. DPT-HiB-HepB 1 - Total 0 0 0 9. OPV 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
5. DPT-HiB-HepB 2 - Total 0 0 0 10. IPV - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
16. FIC - Total 0 0 0 18. Td, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
17. CIC - Total 0 0 0 19. MR, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
C2. Nutrition Services
22. Newborns initiated on breastfeeding
immediately after birth lasting to 90 mins - 28. Infants 6-11 mos. old seen - Total
Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
23. Preterm/LBW infants given iron 29. Infants 6-11 mos. given 1 dose of
supplementation - Total 0 0 0 Vitamin A 100,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
24. Infants 6 mos. old seen - Total 0 0 0 30. Children 12-59 mos seen - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
25. Infants exclusively breastfed until 6th month - 31. Children 12-59 mos. old given 2
Total 0 0 0 doses of Vitamin A 200,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
26. Infants 6 mos. old initiated to complementary 32. Infant 6-11 months old who completed
feeding with continued breastfeeding - Total 0 0 0 MNP supplementation - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
27. Infants 6 mos. old initiated to complementary
feeding but no longer or never been breastfed 33. Children 12-23 mos. seen - Total
- Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
0
40. 1-19 y/o given 2 doses of deworming drug - 42. SAC, 5-9 y/o dewormed (2 doses) -
Total 0 0 0 Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
41. PSAC, 1-4 y/o dewormed (2 doses) - Total 0 0 0
• NHTS 0
• Non-NHTS 0
0
44. Sick Infants 6-11 mos. old seen - Total 47. Sick Children 12-59 mos. old
0 0 0 received Vitamin A - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
45. Sick Infants 6-11 mos. old received 48. Diarrhea cases 0-59 months old seen
Vitamin A - Total 0 0 0 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
49. Diarrhea cases 0-59 months old
46. Sick Children 12-59 mos. old seen - Total
0 0 0 received ORS - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
 To be submitted Qua
Section E. Infectious Disease Preven
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
E1. Filariasis Prevention and Control E2. Schistosomiasis Prevention and Contro
1. No. of individual examined for lymphatic 1. No. of people 5-65 y/o who ingested
filariasis - Total 0 MDA drugs - Total
2. No. of individual examined found positive for 2. No. of patients seen - Total
lymphatic filariasis - Total 0 3. No. of suspected cases seen
3. No. of lymphatic filariasis cases examined with 4. No. acute clinically diagnosed cases -
manifestation of either lymphedema,hydrocele, Total
elephantiasis - Total
0 5. No. of confirmed acute cases - Total
6. No. of chronic clinically diagnosed
cases - Total
Section F. _________________________
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
 ___JANUARY_____ YEAR: ____2020___

M1
AGPAKO__________________________
_________________________
_________________________

BRGY
________________________
________________________
r submission to RHU/MHC

Services and Deworming for Women of Reproductive Age

Total A3. Deworming Services SES Total

Col. 3) (Col. 1) (Col. 2) (Col. 3)

NHTS Non-NHTS
1. No. of women 20-49 years old given 2 doses of
15 deworming drugs - Total
0 0 0
15
0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
on B. Maternal Care and Services
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

a. Number of pregnant women seen in the

first trimester who have normal BMI -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of pregnant women seen in the first
trimester who have low BMI - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

7. No. of pregnant women given iodine

capsules – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
8. No. of pregnant women given one dose
of deworming tablet - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
9. No. of pregnant women screened for
syphilis - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
10. No. of pregnant women tested positive
for syphilis - Total

0 0 0 0
 • NHTS 0
• Non-NHTS 0
11. No. of pregnant women screened for
Hepatitis B - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
18. No. of deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
19. No. of live births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20a. No. of live births with normal birth
weight - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20b. No. of live births with low birth weight
- Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
20c. No. of live births with unknown birth
weight- Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
21. No. of deliveries attended by skilled
health professionals - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col 3)  (Col. 4)
rks Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

24a. No. of deliveries in public health

facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
24b. No. of deliveries in private health
facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
25. No. of non-facility-based deliveries -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
26a. No. of vaginal deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
26b. No. of deliveries by cesarean
section – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
27a. No. of full-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
27b. No. of pre-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B3. Postpartum and Newborn Care
28. No. of postpartum women together
with their newborn who completed at
least 2 postpartum check-ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
 29. No. of postpartum women who
completed iron with folic acid
supplementation - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
30. No. of postpartum women with
Vitamin A supplementation – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
ction C. Child Care and Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)

epB 3 - Total 0 0 0 11. PCV 1 - Total 0 0

0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 12. PCV 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 13. PCV 3 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 14. MMR 1 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
0 0 0 15. MMR 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
1 (November) - Total 0 0 0 20. Td, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
e 1 (November) - Total 0 0 0 21. MR, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

34. Children 12-23 mos. who completed

1 mos. old seen - Total
MNP supplementation - Total
0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
 1 mos. given 1 dose of
35. Children 0-59 mos. seen - Total
100,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos seen - Total 0 0 0 36. Stunted - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos. old given 2
37. Wasted - Total
tamin A 200,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
1 months old who completed
38. Overweight/Obese - Total
lementation - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS

2-23 mos. seen - Total 39. Normal - Total

0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col. 1) (Col 2) (Col 3)

y/o dewormed (2 doses) - 43. Adolescents, 10-19 y/o dewormed

0 0 0 (2 doses) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

ren 12-59 mos. old 50. Diarrhea cases 0-59 mos. received
itamin A - Total 0 0 0 ORS w/ zinc - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old seen 51. Pneumonia cases 0-59 mos. old
0 0 0 seen - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old 52. Pneumonia cases 0-59 mos. old
ORS - Total 0 0 0 completed treatment - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
 To be submitted Quarterly
ous Disease Prevention and Control Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
miasis Prevention and Control E2. Schistosomiasis Prevention and Control (Con't.)
le 5-65 y/o who ingested 7. No. confirmed chronic cases - Total
- Total 0
nts seen - Total 0 8. No. of confirmed cases (acute and
ected cases seen 0 chronic) - Total
clinically diagnosed cases - 9. No. of cases treated - Total
0
rmed acute cases - Total 0 10. No. of confirmed chronic cases
nic clinically diagnosed referred to a hospital facility - Total
al 0
_________________________________________
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
M1
RGY
Total

(Col. 3)

New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
 0 0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0 0
0
0
0 0
0
0
0 0
0
0
 0 0
0
0

Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
 Total
(Col 4)

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Total
(Col 4)
0
0
0
0
0
0

0
0
0
 0
0
0
0
0
0

0
0
0

0
0
0

0
0
0
Total
(Col 4)

0
0
0

0
0
0

0
0
0

0
0
0
 Total
(Col 4)
't.)

Total
(Col 4)
 FHSIS REPORT for the MONTH: ___JANUARY_____
Name of Barangay: _____TAGPAKO_________
Name of BHS: _______________________
Name of Municipality/City: _______________________
Name of Province: ________________________
Projected Population of the Year: _______________________
For submission to RHU/MHC

Section A. Family Planning Services and Dewor

A1. Modern FP Unmet Need Age Total

(Col. 1) (Col. 2) (Col. 3)

10-14 15-19 20-49
1. No. of WRA with unmet
need for modern FP - Total 5 5 5
15
• NHTS 5 5 5 15
• Non-NHTS 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
a. Female Sterilization/ BTL - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
b. Male Sterilization/ NSV-Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
c. Condom - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d. Pills - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
 d.1 Pills-POP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d.2 Pills-COC - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
e. Injectables (DMPA/ POI) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
f. Implant - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g. IUD (IUD-I and IUD-PP) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.1 IUD-I- Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.2 IUD-PP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
h. NFP-LAM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
i. NFP-BBT - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
j. NFP-CMM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
k. NFP-STM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
l. NFP-SDM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
m. Total Current Users 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
Section B. Maternal Care
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
1. No. of pregnant women w/
at least 4 prenatal check-
ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
2. No. of pregnant women
assessed of their nutritional
status during the 1st tri. -Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
c. No. of pregnant women
seen in the first trimester
who have high BMI - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
3. No. of pregnant women for
the first time given 2 doses of
Td vaccination - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
4. No. of pregnant women for
the 2nd or more times given
at least 3 doses of Td
vaccination (Td2 Plus) - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
5. No. of pregnant women who
completed the dose of iron
with folic acid
supplementation - Total 0 0 0 0
 • NHTS 0
• Non-NHTS 0
6. No. of pregnant women who
completed doses of calcium
carbonate supplementation -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
12. No. of pregnant women
tested positive for Hepatitis
B - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
13. No. of pregnant women
screened for HIV - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
14. No. of pregnant women
tested for CBC or Hgb&Hct
count - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
15. No. of pregnant women
tested for CBC or Hgb&Hct
count diagnosed with
anemia - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
16. No. of pregnant women
screened for gestational
diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
17.   No. of pregnant women
tested positive for
gestational diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col 3)  (Col. 4)
 Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
a. No. of deliveries attended
by a doctor - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by a nurse – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
c. No. of deliveries attended
by midwives - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
22. No. of deliveries attended by
non-skilled health
professionals - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
a. No. of deliveries attended
by Hilot/TBA - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by others - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
23. No. of health facility-based
deliveries - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
27c. No. of fetal deaths - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
27d. No. of abortion/
miscarriage - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0

Section C. Child Care a

Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
C1. Immunization Services
1. CPAB - Total 0 0 0 6. DPT-HiB-HepB 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
2. BCG - Total 0 0 0 7. OPV 1 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
3. HepB, within 24 hours. - Total 0 0 0 8. OPV 2 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
4. DPT-HiB-HepB 1 - Total 0 0 0 9. OPV 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
5. DPT-HiB-HepB 2 - Total 0 0 0 10. IPV - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
16. FIC - Total 0 0 0 18. Td, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
17. CIC - Total 0 0 0 19. MR, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
C2. Nutrition Services
22. Newborns initiated on breastfeeding
immediately after birth lasting to 90 mins - 28. Infants 6-11 mos. old seen - Total
Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
23. Preterm/LBW infants given iron 29. Infants 6-11 mos. given 1 dose of
supplementation - Total 0 0 0 Vitamin A 100,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
24. Infants 6 mos. old seen - Total 0 0 0 30. Children 12-59 mos seen - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
25. Infants exclusively breastfed until 6th month - 31. Children 12-59 mos. old given 2
Total 0 0 0 doses of Vitamin A 200,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
26. Infants 6 mos. old initiated to complementary 32. Infant 6-11 months old who completed
feeding with continued breastfeeding - Total 0 0 0 MNP supplementation - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
27. Infants 6 mos. old initiated to complementary
feeding but no longer or never been breastfed 33. Children 12-23 mos. seen - Total
- Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
0
40. 1-19 y/o given 2 doses of deworming drug - 42. SAC, 5-9 y/o dewormed (2 doses) -
Total 0 0 0 Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
41. PSAC, 1-4 y/o dewormed (2 doses) - Total 0 0 0
• NHTS 0
• Non-NHTS 0
0
44. Sick Infants 6-11 mos. old seen - Total 47. Sick Children 12-59 mos. old
0 0 0 received Vitamin A - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
45. Sick Infants 6-11 mos. old received 48. Diarrhea cases 0-59 months old seen
Vitamin A - Total 0 0 0 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
49. Diarrhea cases 0-59 months old
46. Sick Children 12-59 mos. old seen - Total
0 0 0 received ORS - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
 To be submitted Qua
Section E. Infectious Disease Preven
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
E1. Filariasis Prevention and Control E2. Schistosomiasis Prevention and Contro
1. No. of individual examined for lymphatic 1. No. of people 5-65 y/o who ingested
filariasis - Total 0 MDA drugs - Total
2. No. of individual examined found positive for 2. No. of patients seen - Total
lymphatic filariasis - Total 0 3. No. of suspected cases seen
3. No. of lymphatic filariasis cases examined with 4. No. acute clinically diagnosed cases -
manifestation of either lymphedema,hydrocele, Total
elephantiasis - Total
0 5. No. of confirmed acute cases - Total
6. No. of chronic clinically diagnosed
cases - Total
Section F. _________________________
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
 ___JANUARY_____ YEAR: ____2020___

M1
AGPAKO__________________________
_________________________
_________________________

BRGY
________________________
________________________
r submission to RHU/MHC

Services and Deworming for Women of Reproductive Age

Total A3. Deworming Services SES Total

Col. 3) (Col. 1) (Col. 2) (Col. 3)

NHTS Non-NHTS
1. No. of women 20-49 years old given 2 doses of
15 deworming drugs - Total
0 0 0
15
0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
on B. Maternal Care and Services
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

a. Number of pregnant women seen in the

first trimester who have normal BMI -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of pregnant women seen in the first
trimester who have low BMI - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

7. No. of pregnant women given iodine

capsules – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
8. No. of pregnant women given one dose
of deworming tablet - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
9. No. of pregnant women screened for
syphilis - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
10. No. of pregnant women tested positive
for syphilis - Total

0 0 0 0
 • NHTS 0
• Non-NHTS 0
11. No. of pregnant women screened for
Hepatitis B - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
18. No. of deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
19. No. of live births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20a. No. of live births with normal birth
weight - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20b. No. of live births with low birth weight
- Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
20c. No. of live births with unknown birth
weight- Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
21. No. of deliveries attended by skilled
health professionals - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col 3)  (Col. 4)
rks Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

24a. No. of deliveries in public health

facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
24b. No. of deliveries in private health
facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
25. No. of non-facility-based deliveries -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
26a. No. of vaginal deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
26b. No. of deliveries by cesarean
section – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
27a. No. of full-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
27b. No. of pre-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B3. Postpartum and Newborn Care
28. No. of postpartum women together
with their newborn who completed at
least 2 postpartum check-ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
 29. No. of postpartum women who
completed iron with folic acid
supplementation - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
30. No. of postpartum women with
Vitamin A supplementation – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
ction C. Child Care and Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)

epB 3 - Total 0 0 0 11. PCV 1 - Total 0 0

0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 12. PCV 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 13. PCV 3 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 14. MMR 1 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
0 0 0 15. MMR 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
1 (November) - Total 0 0 0 20. Td, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
e 1 (November) - Total 0 0 0 21. MR, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

34. Children 12-23 mos. who completed

1 mos. old seen - Total
MNP supplementation - Total
0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
 1 mos. given 1 dose of
35. Children 0-59 mos. seen - Total
100,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos seen - Total 0 0 0 36. Stunted - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos. old given 2
37. Wasted - Total
tamin A 200,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
1 months old who completed
38. Overweight/Obese - Total
lementation - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS

2-23 mos. seen - Total 39. Normal - Total

0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col. 1) (Col 2) (Col 3)

y/o dewormed (2 doses) - 43. Adolescents, 10-19 y/o dewormed

0 0 0 (2 doses) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

ren 12-59 mos. old 50. Diarrhea cases 0-59 mos. received
itamin A - Total 0 0 0 ORS w/ zinc - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old seen 51. Pneumonia cases 0-59 mos. old
0 0 0 seen - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old 52. Pneumonia cases 0-59 mos. old
ORS - Total 0 0 0 completed treatment - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
 To be submitted Quarterly
ous Disease Prevention and Control Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
miasis Prevention and Control E2. Schistosomiasis Prevention and Control (Con't.)
le 5-65 y/o who ingested 7. No. confirmed chronic cases - Total
- Total 0
nts seen - Total 0 8. No. of confirmed cases (acute and
ected cases seen 0 chronic) - Total
clinically diagnosed cases - 9. No. of cases treated - Total
0
rmed acute cases - Total 0 10. No. of confirmed chronic cases
nic clinically diagnosed referred to a hospital facility - Total
al 0
_________________________________________
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
M1
RGY
Total

(Col. 3)

New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
 0 0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0 0
0
0
0 0
0
0
0 0
0
0
 0 0
0
0

Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
 Total
(Col 4)

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Total
(Col 4)
0
0
0
0
0
0

0
0
0
 0
0
0
0
0
0

0
0
0

0
0
0

0
0
0
Total
(Col 4)

0
0
0

0
0
0

0
0
0

0
0
0
 Total
(Col 4)
't.)

Total
(Col 4)
 FHSIS REPORT for the MONTH: ___JANUARY_____
Name of Barangay: _____TAGPAKO_________
Name of BHS: _______________________
Name of Municipality/City: _______________________
Name of Province: ________________________
Projected Population of the Year: _______________________
For submission to RHU/MHC

Section A. Family Planning Services and Dewor

A1. Modern FP Unmet Need Age Total

(Col. 1) (Col. 2) (Col. 3)

10-14 15-19 20-49
1. No. of WRA with unmet
need for modern FP - Total 5 5 5
15
• NHTS 5 5 5 15
• Non-NHTS 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
a. Female Sterilization/ BTL - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
b. Male Sterilization/ NSV-Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
c. Condom - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d. Pills - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
 d.1 Pills-POP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d.2 Pills-COC - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
e. Injectables (DMPA/ POI) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
f. Implant - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g. IUD (IUD-I and IUD-PP) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.1 IUD-I- Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.2 IUD-PP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
h. NFP-LAM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
i. NFP-BBT - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
j. NFP-CMM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
k. NFP-STM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
l. NFP-SDM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
m. Total Current Users 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
Section B. Maternal Care
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
1. No. of pregnant women w/
at least 4 prenatal check-
ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
2. No. of pregnant women
assessed of their nutritional
status during the 1st tri. -Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
c. No. of pregnant women
seen in the first trimester
who have high BMI - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
3. No. of pregnant women for
the first time given 2 doses of
Td vaccination - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
4. No. of pregnant women for
the 2nd or more times given
at least 3 doses of Td
vaccination (Td2 Plus) - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
5. No. of pregnant women who
completed the dose of iron
with folic acid
supplementation - Total 0 0 0 0
 • NHTS 0
• Non-NHTS 0
6. No. of pregnant women who
completed doses of calcium
carbonate supplementation -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
12. No. of pregnant women
tested positive for Hepatitis
B - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
13. No. of pregnant women
screened for HIV - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
14. No. of pregnant women
tested for CBC or Hgb&Hct
count - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
15. No. of pregnant women
tested for CBC or Hgb&Hct
count diagnosed with
anemia - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
16. No. of pregnant women
screened for gestational
diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
17.   No. of pregnant women
tested positive for
gestational diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col 3)  (Col. 4)
 Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
a. No. of deliveries attended
by a doctor - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by a nurse – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
c. No. of deliveries attended
by midwives - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
22. No. of deliveries attended by
non-skilled health
professionals - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
a. No. of deliveries attended
by Hilot/TBA - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by others - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
23. No. of health facility-based
deliveries - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
27c. No. of fetal deaths - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
27d. No. of abortion/
miscarriage - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0

Section C. Child Care a

Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
C1. Immunization Services
1. CPAB - Total 0 0 0 6. DPT-HiB-HepB 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
2. BCG - Total 0 0 0 7. OPV 1 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
3. HepB, within 24 hours. - Total 0 0 0 8. OPV 2 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
4. DPT-HiB-HepB 1 - Total 0 0 0 9. OPV 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
5. DPT-HiB-HepB 2 - Total 0 0 0 10. IPV - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
16. FIC - Total 0 0 0 18. Td, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
17. CIC - Total 0 0 0 19. MR, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
C2. Nutrition Services
22. Newborns initiated on breastfeeding
immediately after birth lasting to 90 mins - 28. Infants 6-11 mos. old seen - Total
Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
23. Preterm/LBW infants given iron 29. Infants 6-11 mos. given 1 dose of
supplementation - Total 0 0 0 Vitamin A 100,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
24. Infants 6 mos. old seen - Total 0 0 0 30. Children 12-59 mos seen - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
25. Infants exclusively breastfed until 6th month - 31. Children 12-59 mos. old given 2
Total 0 0 0 doses of Vitamin A 200,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
26. Infants 6 mos. old initiated to complementary 32. Infant 6-11 months old who completed
feeding with continued breastfeeding - Total 0 0 0 MNP supplementation - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
27. Infants 6 mos. old initiated to complementary
feeding but no longer or never been breastfed 33. Children 12-23 mos. seen - Total
- Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
0
40. 1-19 y/o given 2 doses of deworming drug - 42. SAC, 5-9 y/o dewormed (2 doses) -
Total 0 0 0 Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
41. PSAC, 1-4 y/o dewormed (2 doses) - Total 0 0 0
• NHTS 0
• Non-NHTS 0
0
44. Sick Infants 6-11 mos. old seen - Total 47. Sick Children 12-59 mos. old
0 0 0 received Vitamin A - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
45. Sick Infants 6-11 mos. old received 48. Diarrhea cases 0-59 months old seen
Vitamin A - Total 0 0 0 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
49. Diarrhea cases 0-59 months old
46. Sick Children 12-59 mos. old seen - Total
0 0 0 received ORS - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
 To be submitted Qua
Section E. Infectious Disease Preven
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
E1. Filariasis Prevention and Control E2. Schistosomiasis Prevention and Contro
1. No. of individual examined for lymphatic 1. No. of people 5-65 y/o who ingested
filariasis - Total 0 MDA drugs - Total
2. No. of individual examined found positive for 2. No. of patients seen - Total
lymphatic filariasis - Total 0 3. No. of suspected cases seen
3. No. of lymphatic filariasis cases examined with 4. No. acute clinically diagnosed cases -
manifestation of either lymphedema,hydrocele, Total
elephantiasis - Total
0 5. No. of confirmed acute cases - Total
6. No. of chronic clinically diagnosed
cases - Total
Section F. _________________________
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
 ___JANUARY_____ YEAR: ____2020___

M1
AGPAKO__________________________
_________________________
_________________________

BRGY
________________________
________________________
r submission to RHU/MHC

Services and Deworming for Women of Reproductive Age

Total A3. Deworming Services SES Total

Col. 3) (Col. 1) (Col. 2) (Col. 3)

NHTS Non-NHTS
1. No. of women 20-49 years old given 2 doses of
15 deworming drugs - Total
0 0 0
15
0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
on B. Maternal Care and Services
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

a. Number of pregnant women seen in the

first trimester who have normal BMI -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of pregnant women seen in the first
trimester who have low BMI - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

7. No. of pregnant women given iodine

capsules – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
8. No. of pregnant women given one dose
of deworming tablet - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
9. No. of pregnant women screened for
syphilis - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
10. No. of pregnant women tested positive
for syphilis - Total

0 0 0 0
 • NHTS 0
• Non-NHTS 0
11. No. of pregnant women screened for
Hepatitis B - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
18. No. of deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
19. No. of live births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20a. No. of live births with normal birth
weight - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20b. No. of live births with low birth weight
- Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
20c. No. of live births with unknown birth
weight- Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
21. No. of deliveries attended by skilled
health professionals - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col 3)  (Col. 4)
rks Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

24a. No. of deliveries in public health

facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
24b. No. of deliveries in private health
facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
25. No. of non-facility-based deliveries -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
26a. No. of vaginal deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
26b. No. of deliveries by cesarean
section – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
27a. No. of full-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
27b. No. of pre-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B3. Postpartum and Newborn Care
28. No. of postpartum women together
with their newborn who completed at
least 2 postpartum check-ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
 29. No. of postpartum women who
completed iron with folic acid
supplementation - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
30. No. of postpartum women with
Vitamin A supplementation – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
ction C. Child Care and Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)

epB 3 - Total 0 0 0 11. PCV 1 - Total 0 0

0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 12. PCV 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 13. PCV 3 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 14. MMR 1 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
0 0 0 15. MMR 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
1 (November) - Total 0 0 0 20. Td, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
e 1 (November) - Total 0 0 0 21. MR, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

34. Children 12-23 mos. who completed

1 mos. old seen - Total
MNP supplementation - Total
0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
 1 mos. given 1 dose of
35. Children 0-59 mos. seen - Total
100,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos seen - Total 0 0 0 36. Stunted - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos. old given 2
37. Wasted - Total
tamin A 200,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
1 months old who completed
38. Overweight/Obese - Total
lementation - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS

2-23 mos. seen - Total 39. Normal - Total

0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col. 1) (Col 2) (Col 3)

y/o dewormed (2 doses) - 43. Adolescents, 10-19 y/o dewormed

0 0 0 (2 doses) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

ren 12-59 mos. old 50. Diarrhea cases 0-59 mos. received
itamin A - Total 0 0 0 ORS w/ zinc - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old seen 51. Pneumonia cases 0-59 mos. old
0 0 0 seen - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old 52. Pneumonia cases 0-59 mos. old
ORS - Total 0 0 0 completed treatment - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
 To be submitted Quarterly
ous Disease Prevention and Control Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
miasis Prevention and Control E2. Schistosomiasis Prevention and Control (Con't.)
le 5-65 y/o who ingested 7. No. confirmed chronic cases - Total
- Total 0
nts seen - Total 0 8. No. of confirmed cases (acute and
ected cases seen 0 chronic) - Total
clinically diagnosed cases - 9. No. of cases treated - Total
0
rmed acute cases - Total 0 10. No. of confirmed chronic cases
nic clinically diagnosed referred to a hospital facility - Total
al 0
_________________________________________
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
M1
RGY
Total

(Col. 3)

New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
 0 0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0 0
0
0
0 0
0
0
0 0
0
0
 0 0
0
0

Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
 Total
(Col 4)

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Total
(Col 4)
0
0
0
0
0
0

0
0
0
 0
0
0
0
0
0

0
0
0

0
0
0

0
0
0
Total
(Col 4)

0
0
0

0
0
0

0
0
0

0
0
0
 Total
(Col 4)
't.)

Total
(Col 4)
 FHSIS REPORT for the MONTH: ___JANUARY_____
Name of Barangay: _____TAGPAKO_________
Name of BHS: _______________________
Name of Municipality/City: _______________________
Name of Province: ________________________
Projected Population of the Year: _______________________
For submission to RHU/MHC

Section A. Family Planning Services and Dewor

A1. Modern FP Unmet Need Age Total

(Col. 1) (Col. 2) (Col. 3)

10-14 15-19 20-49
1. No. of WRA with unmet
need for modern FP - Total 5 5 5
15
• NHTS 5 5 5 15
• Non-NHTS 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
a. Female Sterilization/ BTL - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
b. Male Sterilization/ NSV-Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
c. Condom - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d. Pills - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
 d.1 Pills-POP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d.2 Pills-COC - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
e. Injectables (DMPA/ POI) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
f. Implant - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g. IUD (IUD-I and IUD-PP) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.1 IUD-I- Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.2 IUD-PP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
h. NFP-LAM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
i. NFP-BBT - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
j. NFP-CMM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
k. NFP-STM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
l. NFP-SDM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
m. Total Current Users 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
Section B. Maternal Care
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
1. No. of pregnant women w/
at least 4 prenatal check-
ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
2. No. of pregnant women
assessed of their nutritional
status during the 1st tri. -Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
c. No. of pregnant women
seen in the first trimester
who have high BMI - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
3. No. of pregnant women for
the first time given 2 doses of
Td vaccination - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
4. No. of pregnant women for
the 2nd or more times given
at least 3 doses of Td
vaccination (Td2 Plus) - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
5. No. of pregnant women who
completed the dose of iron
with folic acid
supplementation - Total 0 0 0 0
 • NHTS 0
• Non-NHTS 0
6. No. of pregnant women who
completed doses of calcium
carbonate supplementation -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
12. No. of pregnant women
tested positive for Hepatitis
B - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
13. No. of pregnant women
screened for HIV - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
14. No. of pregnant women
tested for CBC or Hgb&Hct
count - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
15. No. of pregnant women
tested for CBC or Hgb&Hct
count diagnosed with
anemia - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
16. No. of pregnant women
screened for gestational
diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
17.   No. of pregnant women
tested positive for
gestational diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col 3)  (Col. 4)
 Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
a. No. of deliveries attended
by a doctor - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by a nurse – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
c. No. of deliveries attended
by midwives - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
22. No. of deliveries attended by
non-skilled health
professionals - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
a. No. of deliveries attended
by Hilot/TBA - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by others - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
23. No. of health facility-based
deliveries - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
27c. No. of fetal deaths - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
27d. No. of abortion/
miscarriage - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0

Section C. Child Care a

Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
C1. Immunization Services
1. CPAB - Total 0 0 0 6. DPT-HiB-HepB 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
2. BCG - Total 0 0 0 7. OPV 1 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
3. HepB, within 24 hours. - Total 0 0 0 8. OPV 2 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
4. DPT-HiB-HepB 1 - Total 0 0 0 9. OPV 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
5. DPT-HiB-HepB 2 - Total 0 0 0 10. IPV - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
16. FIC - Total 0 0 0 18. Td, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
17. CIC - Total 0 0 0 19. MR, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
C2. Nutrition Services
22. Newborns initiated on breastfeeding
immediately after birth lasting to 90 mins - 28. Infants 6-11 mos. old seen - Total
Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
23. Preterm/LBW infants given iron 29. Infants 6-11 mos. given 1 dose of
supplementation - Total 0 0 0 Vitamin A 100,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
24. Infants 6 mos. old seen - Total 0 0 0 30. Children 12-59 mos seen - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
25. Infants exclusively breastfed until 6th month - 31. Children 12-59 mos. old given 2
Total 0 0 0 doses of Vitamin A 200,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
26. Infants 6 mos. old initiated to complementary 32. Infant 6-11 months old who completed
feeding with continued breastfeeding - Total 0 0 0 MNP supplementation - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
27. Infants 6 mos. old initiated to complementary
feeding but no longer or never been breastfed 33. Children 12-23 mos. seen - Total
- Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
0
40. 1-19 y/o given 2 doses of deworming drug - 42. SAC, 5-9 y/o dewormed (2 doses) -
Total 0 0 0 Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
41. PSAC, 1-4 y/o dewormed (2 doses) - Total 0 0 0
• NHTS 0
• Non-NHTS 0
0
44. Sick Infants 6-11 mos. old seen - Total 47. Sick Children 12-59 mos. old
0 0 0 received Vitamin A - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
45. Sick Infants 6-11 mos. old received 48. Diarrhea cases 0-59 months old seen
Vitamin A - Total 0 0 0 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
49. Diarrhea cases 0-59 months old
46. Sick Children 12-59 mos. old seen - Total
0 0 0 received ORS - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
 To be submitted Qua
Section E. Infectious Disease Preven
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
E1. Filariasis Prevention and Control E2. Schistosomiasis Prevention and Contro
1. No. of individual examined for lymphatic 1. No. of people 5-65 y/o who ingested
filariasis - Total 0 MDA drugs - Total
2. No. of individual examined found positive for 2. No. of patients seen - Total
lymphatic filariasis - Total 0 3. No. of suspected cases seen
3. No. of lymphatic filariasis cases examined with 4. No. acute clinically diagnosed cases -
manifestation of either lymphedema,hydrocele, Total
elephantiasis - Total
0 5. No. of confirmed acute cases - Total
6. No. of chronic clinically diagnosed
cases - Total
Section F. _________________________
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
 ___JANUARY_____ YEAR: ____2020___

M1
AGPAKO__________________________
_________________________
_________________________

BRGY
________________________
________________________
r submission to RHU/MHC

Services and Deworming for Women of Reproductive Age

Total A3. Deworming Services SES Total

Col. 3) (Col. 1) (Col. 2) (Col. 3)

NHTS Non-NHTS
1. No. of women 20-49 years old given 2 doses of
15 deworming drugs - Total
0 0 0
15
0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
on B. Maternal Care and Services
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

a. Number of pregnant women seen in the

first trimester who have normal BMI -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of pregnant women seen in the first
trimester who have low BMI - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

7. No. of pregnant women given iodine

capsules – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
8. No. of pregnant women given one dose
of deworming tablet - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
9. No. of pregnant women screened for
syphilis - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
10. No. of pregnant women tested positive
for syphilis - Total

0 0 0 0
 • NHTS 0
• Non-NHTS 0
11. No. of pregnant women screened for
Hepatitis B - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
18. No. of deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
19. No. of live births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20a. No. of live births with normal birth
weight - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20b. No. of live births with low birth weight
- Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
20c. No. of live births with unknown birth
weight- Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
21. No. of deliveries attended by skilled
health professionals - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col 3)  (Col. 4)
rks Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

24a. No. of deliveries in public health

facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
24b. No. of deliveries in private health
facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
25. No. of non-facility-based deliveries -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
26a. No. of vaginal deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
26b. No. of deliveries by cesarean
section – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
27a. No. of full-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
27b. No. of pre-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B3. Postpartum and Newborn Care
28. No. of postpartum women together
with their newborn who completed at
least 2 postpartum check-ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
 29. No. of postpartum women who
completed iron with folic acid
supplementation - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
30. No. of postpartum women with
Vitamin A supplementation – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
ction C. Child Care and Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)

epB 3 - Total 0 0 0 11. PCV 1 - Total 0 0

0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 12. PCV 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 13. PCV 3 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 14. MMR 1 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
0 0 0 15. MMR 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
1 (November) - Total 0 0 0 20. Td, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
e 1 (November) - Total 0 0 0 21. MR, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

34. Children 12-23 mos. who completed

1 mos. old seen - Total
MNP supplementation - Total
0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
 1 mos. given 1 dose of
35. Children 0-59 mos. seen - Total
100,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos seen - Total 0 0 0 36. Stunted - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos. old given 2
37. Wasted - Total
tamin A 200,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
1 months old who completed
38. Overweight/Obese - Total
lementation - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS

2-23 mos. seen - Total 39. Normal - Total

0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col. 1) (Col 2) (Col 3)

y/o dewormed (2 doses) - 43. Adolescents, 10-19 y/o dewormed

0 0 0 (2 doses) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

ren 12-59 mos. old 50. Diarrhea cases 0-59 mos. received
itamin A - Total 0 0 0 ORS w/ zinc - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old seen 51. Pneumonia cases 0-59 mos. old
0 0 0 seen - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old 52. Pneumonia cases 0-59 mos. old
ORS - Total 0 0 0 completed treatment - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
 To be submitted Quarterly
ous Disease Prevention and Control Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
miasis Prevention and Control E2. Schistosomiasis Prevention and Control (Con't.)
le 5-65 y/o who ingested 7. No. confirmed chronic cases - Total
- Total 0
nts seen - Total 0 8. No. of confirmed cases (acute and
ected cases seen 0 chronic) - Total
clinically diagnosed cases - 9. No. of cases treated - Total
0
rmed acute cases - Total 0 10. No. of confirmed chronic cases
nic clinically diagnosed referred to a hospital facility - Total
al 0
_________________________________________
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
M1
RGY
Total

(Col. 3)

New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
 0 0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0 0
0
0
0 0
0
0
0 0
0
0
 0 0
0
0

Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
 Total
(Col 4)

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Total
(Col 4)
0
0
0
0
0
0

0
0
0
 0
0
0
0
0
0

0
0
0

0
0
0

0
0
0
Total
(Col 4)

0
0
0

0
0
0

0
0
0

0
0
0
 Total
(Col 4)
't.)

Total
(Col 4)
 FHSIS REPORT for the MONTH: ___JANUARY_____
Name of Barangay: _____TAGPAKO_________
Name of BHS: _______________________
Name of Municipality/City: _______________________
Name of Province: ________________________
Projected Population of the Year: _______________________
For submission to RHU/MHC

Section A. Family Planning Services and Dewor

A1. Modern FP Unmet Need Age Total

(Col. 1) (Col. 2) (Col. 3)

10-14 15-19 20-49
1. No. of WRA with unmet
need for modern FP - Total 5 5 5
15
• NHTS 5 5 5 15
• Non-NHTS 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
a. Female Sterilization/ BTL - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
b. Male Sterilization/ NSV-Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
c. Condom - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d. Pills - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
 d.1 Pills-POP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d.2 Pills-COC - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
e. Injectables (DMPA/ POI) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
f. Implant - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g. IUD (IUD-I and IUD-PP) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.1 IUD-I- Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.2 IUD-PP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
h. NFP-LAM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
i. NFP-BBT - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
j. NFP-CMM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
k. NFP-STM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
l. NFP-SDM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
m. Total Current Users 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
Section B. Maternal Care
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
1. No. of pregnant women w/
at least 4 prenatal check-
ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
2. No. of pregnant women
assessed of their nutritional
status during the 1st tri. -Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
c. No. of pregnant women
seen in the first trimester
who have high BMI - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
3. No. of pregnant women for
the first time given 2 doses of
Td vaccination - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
4. No. of pregnant women for
the 2nd or more times given
at least 3 doses of Td
vaccination (Td2 Plus) - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
5. No. of pregnant women who
completed the dose of iron
with folic acid
supplementation - Total 0 0 0 0
 • NHTS 0
• Non-NHTS 0
6. No. of pregnant women who
completed doses of calcium
carbonate supplementation -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
12. No. of pregnant women
tested positive for Hepatitis
B - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
13. No. of pregnant women
screened for HIV - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
14. No. of pregnant women
tested for CBC or Hgb&Hct
count - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
15. No. of pregnant women
tested for CBC or Hgb&Hct
count diagnosed with
anemia - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
16. No. of pregnant women
screened for gestational
diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
17.   No. of pregnant women
tested positive for
gestational diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col 3)  (Col. 4)
 Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
a. No. of deliveries attended
by a doctor - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by a nurse – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
c. No. of deliveries attended
by midwives - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
22. No. of deliveries attended by
non-skilled health
professionals - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
a. No. of deliveries attended
by Hilot/TBA - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by others - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
23. No. of health facility-based
deliveries - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
27c. No. of fetal deaths - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
27d. No. of abortion/
miscarriage - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0

Section C. Child Care a

Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
C1. Immunization Services
1. CPAB - Total 0 0 0 6. DPT-HiB-HepB 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
2. BCG - Total 0 0 0 7. OPV 1 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
3. HepB, within 24 hours. - Total 0 0 0 8. OPV 2 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
4. DPT-HiB-HepB 1 - Total 0 0 0 9. OPV 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
5. DPT-HiB-HepB 2 - Total 0 0 0 10. IPV - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
16. FIC - Total 0 0 0 18. Td, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
17. CIC - Total 0 0 0 19. MR, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
C2. Nutrition Services
22. Newborns initiated on breastfeeding
immediately after birth lasting to 90 mins - 28. Infants 6-11 mos. old seen - Total
Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
23. Preterm/LBW infants given iron 29. Infants 6-11 mos. given 1 dose of
supplementation - Total 0 0 0 Vitamin A 100,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
24. Infants 6 mos. old seen - Total 0 0 0 30. Children 12-59 mos seen - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
25. Infants exclusively breastfed until 6th month - 31. Children 12-59 mos. old given 2
Total 0 0 0 doses of Vitamin A 200,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
26. Infants 6 mos. old initiated to complementary 32. Infant 6-11 months old who completed
feeding with continued breastfeeding - Total 0 0 0 MNP supplementation - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
27. Infants 6 mos. old initiated to complementary
feeding but no longer or never been breastfed 33. Children 12-23 mos. seen - Total
- Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
0
40. 1-19 y/o given 2 doses of deworming drug - 42. SAC, 5-9 y/o dewormed (2 doses) -
Total 0 0 0 Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
41. PSAC, 1-4 y/o dewormed (2 doses) - Total 0 0 0
• NHTS 0
• Non-NHTS 0
0
44. Sick Infants 6-11 mos. old seen - Total 47. Sick Children 12-59 mos. old
0 0 0 received Vitamin A - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
45. Sick Infants 6-11 mos. old received 48. Diarrhea cases 0-59 months old seen
Vitamin A - Total 0 0 0 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
49. Diarrhea cases 0-59 months old
46. Sick Children 12-59 mos. old seen - Total
0 0 0 received ORS - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
 To be submitted Qua
Section E. Infectious Disease Preven
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
E1. Filariasis Prevention and Control E2. Schistosomiasis Prevention and Contro
1. No. of individual examined for lymphatic 1. No. of people 5-65 y/o who ingested
filariasis - Total 0 MDA drugs - Total
2. No. of individual examined found positive for 2. No. of patients seen - Total
lymphatic filariasis - Total 0 3. No. of suspected cases seen
3. No. of lymphatic filariasis cases examined with 4. No. acute clinically diagnosed cases -
manifestation of either lymphedema,hydrocele, Total
elephantiasis - Total
0 5. No. of confirmed acute cases - Total
6. No. of chronic clinically diagnosed
cases - Total
Section F. _________________________
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
 ___JANUARY_____ YEAR: ____2020___

M1
AGPAKO__________________________
_________________________
_________________________

BRGY
________________________
________________________
r submission to RHU/MHC

Services and Deworming for Women of Reproductive Age

Total A3. Deworming Services SES Total

Col. 3) (Col. 1) (Col. 2) (Col. 3)

NHTS Non-NHTS
1. No. of women 20-49 years old given 2 doses of
15 deworming drugs - Total
0 0 0
15
0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
on B. Maternal Care and Services
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

a. Number of pregnant women seen in the

first trimester who have normal BMI -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of pregnant women seen in the first
trimester who have low BMI - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

7. No. of pregnant women given iodine

capsules – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
8. No. of pregnant women given one dose
of deworming tablet - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
9. No. of pregnant women screened for
syphilis - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
10. No. of pregnant women tested positive
for syphilis - Total

0 0 0 0
 • NHTS 0
• Non-NHTS 0
11. No. of pregnant women screened for
Hepatitis B - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
18. No. of deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
19. No. of live births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20a. No. of live births with normal birth
weight - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20b. No. of live births with low birth weight
- Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
20c. No. of live births with unknown birth
weight- Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
21. No. of deliveries attended by skilled
health professionals - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col 3)  (Col. 4)
rks Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

24a. No. of deliveries in public health

facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
24b. No. of deliveries in private health
facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
25. No. of non-facility-based deliveries -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
26a. No. of vaginal deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
26b. No. of deliveries by cesarean
section – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
27a. No. of full-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
27b. No. of pre-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B3. Postpartum and Newborn Care
28. No. of postpartum women together
with their newborn who completed at
least 2 postpartum check-ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
 29. No. of postpartum women who
completed iron with folic acid
supplementation - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
30. No. of postpartum women with
Vitamin A supplementation – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
ction C. Child Care and Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)

epB 3 - Total 0 0 0 11. PCV 1 - Total 0 0

0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 12. PCV 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 13. PCV 3 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 14. MMR 1 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
0 0 0 15. MMR 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
1 (November) - Total 0 0 0 20. Td, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
e 1 (November) - Total 0 0 0 21. MR, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

34. Children 12-23 mos. who completed

1 mos. old seen - Total
MNP supplementation - Total
0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
 1 mos. given 1 dose of
35. Children 0-59 mos. seen - Total
100,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos seen - Total 0 0 0 36. Stunted - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos. old given 2
37. Wasted - Total
tamin A 200,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
1 months old who completed
38. Overweight/Obese - Total
lementation - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS

2-23 mos. seen - Total 39. Normal - Total

0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col. 1) (Col 2) (Col 3)

y/o dewormed (2 doses) - 43. Adolescents, 10-19 y/o dewormed

0 0 0 (2 doses) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

ren 12-59 mos. old 50. Diarrhea cases 0-59 mos. received
itamin A - Total 0 0 0 ORS w/ zinc - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old seen 51. Pneumonia cases 0-59 mos. old
0 0 0 seen - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old 52. Pneumonia cases 0-59 mos. old
ORS - Total 0 0 0 completed treatment - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
 To be submitted Quarterly
ous Disease Prevention and Control Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
miasis Prevention and Control E2. Schistosomiasis Prevention and Control (Con't.)
le 5-65 y/o who ingested 7. No. confirmed chronic cases - Total
- Total 0
nts seen - Total 0 8. No. of confirmed cases (acute and
ected cases seen 0 chronic) - Total
clinically diagnosed cases - 9. No. of cases treated - Total
0
rmed acute cases - Total 0 10. No. of confirmed chronic cases
nic clinically diagnosed referred to a hospital facility - Total
al 0
_________________________________________
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
M1
RGY
Total

(Col. 3)

New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
 0 0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0 0
0
0
0 0
0
0
0 0
0
0
 0 0
0
0

Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
 Total
(Col 4)

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Total
(Col 4)
0
0
0
0
0
0

0
0
0
 0
0
0
0
0
0

0
0
0

0
0
0

0
0
0
Total
(Col 4)

0
0
0

0
0
0

0
0
0

0
0
0
 Total
(Col 4)
't.)

Total
(Col 4)
 FHSIS REPORT for the MONTH: ___JANUARY_____
Name of Barangay: _____TAGPAKO_________
Name of BHS: _______________________
Name of Municipality/City: _______________________
Name of Province: ________________________
Projected Population of the Year: _______________________
For submission to RHU/MHC

Section A. Family Planning Services and Dewor

A1. Modern FP Unmet Need Age Total

(Col. 1) (Col. 2) (Col. 3)

10-14 15-19 20-49
1. No. of WRA with unmet
need for modern FP - Total 5 5 5
15
• NHTS 5 5 5 15
• Non-NHTS 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
a. Female Sterilization/ BTL - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
b. Male Sterilization/ NSV-Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
c. Condom - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d. Pills - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
 d.1 Pills-POP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d.2 Pills-COC - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
e. Injectables (DMPA/ POI) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
f. Implant - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g. IUD (IUD-I and IUD-PP) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.1 IUD-I- Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.2 IUD-PP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
h. NFP-LAM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
i. NFP-BBT - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
j. NFP-CMM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
k. NFP-STM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
l. NFP-SDM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
m. Total Current Users 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
Section B. Maternal Care
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
1. No. of pregnant women w/
at least 4 prenatal check-
ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
2. No. of pregnant women
assessed of their nutritional
status during the 1st tri. -Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
c. No. of pregnant women
seen in the first trimester
who have high BMI - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
3. No. of pregnant women for
the first time given 2 doses of
Td vaccination - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
4. No. of pregnant women for
the 2nd or more times given
at least 3 doses of Td
vaccination (Td2 Plus) - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
5. No. of pregnant women who
completed the dose of iron
with folic acid
supplementation - Total 0 0 0 0
 • NHTS 0
• Non-NHTS 0
6. No. of pregnant women who
completed doses of calcium
carbonate supplementation -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
12. No. of pregnant women
tested positive for Hepatitis
B - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
13. No. of pregnant women
screened for HIV - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
14. No. of pregnant women
tested for CBC or Hgb&Hct
count - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
15. No. of pregnant women
tested for CBC or Hgb&Hct
count diagnosed with
anemia - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
16. No. of pregnant women
screened for gestational
diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
17.   No. of pregnant women
tested positive for
gestational diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col 3)  (Col. 4)
 Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
a. No. of deliveries attended
by a doctor - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by a nurse – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
c. No. of deliveries attended
by midwives - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
22. No. of deliveries attended by
non-skilled health
professionals - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
a. No. of deliveries attended
by Hilot/TBA - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by others - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
23. No. of health facility-based
deliveries - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
27c. No. of fetal deaths - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
27d. No. of abortion/
miscarriage - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0

Section C. Child Care a

Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
C1. Immunization Services
1. CPAB - Total 0 0 0 6. DPT-HiB-HepB 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
2. BCG - Total 0 0 0 7. OPV 1 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
3. HepB, within 24 hours. - Total 0 0 0 8. OPV 2 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
4. DPT-HiB-HepB 1 - Total 0 0 0 9. OPV 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
5. DPT-HiB-HepB 2 - Total 0 0 0 10. IPV - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
16. FIC - Total 0 0 0 18. Td, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
17. CIC - Total 0 0 0 19. MR, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
C2. Nutrition Services
22. Newborns initiated on breastfeeding
immediately after birth lasting to 90 mins - 28. Infants 6-11 mos. old seen - Total
Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
23. Preterm/LBW infants given iron 29. Infants 6-11 mos. given 1 dose of
supplementation - Total 0 0 0 Vitamin A 100,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
24. Infants 6 mos. old seen - Total 0 0 0 30. Children 12-59 mos seen - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
25. Infants exclusively breastfed until 6th month - 31. Children 12-59 mos. old given 2
Total 0 0 0 doses of Vitamin A 200,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
26. Infants 6 mos. old initiated to complementary 32. Infant 6-11 months old who completed
feeding with continued breastfeeding - Total 0 0 0 MNP supplementation - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
27. Infants 6 mos. old initiated to complementary
feeding but no longer or never been breastfed 33. Children 12-23 mos. seen - Total
- Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
0
40. 1-19 y/o given 2 doses of deworming drug - 42. SAC, 5-9 y/o dewormed (2 doses) -
Total 0 0 0 Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
41. PSAC, 1-4 y/o dewormed (2 doses) - Total 0 0 0
• NHTS 0
• Non-NHTS 0
0
44. Sick Infants 6-11 mos. old seen - Total 47. Sick Children 12-59 mos. old
0 0 0 received Vitamin A - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
45. Sick Infants 6-11 mos. old received 48. Diarrhea cases 0-59 months old seen
Vitamin A - Total 0 0 0 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
49. Diarrhea cases 0-59 months old
46. Sick Children 12-59 mos. old seen - Total
0 0 0 received ORS - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
 To be submitted Qua
Section E. Infectious Disease Preven
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
E1. Filariasis Prevention and Control E2. Schistosomiasis Prevention and Contro
1. No. of individual examined for lymphatic 1. No. of people 5-65 y/o who ingested
filariasis - Total 0 MDA drugs - Total
2. No. of individual examined found positive for 2. No. of patients seen - Total
lymphatic filariasis - Total 0 3. No. of suspected cases seen
3. No. of lymphatic filariasis cases examined with 4. No. acute clinically diagnosed cases -
manifestation of either lymphedema,hydrocele, Total
elephantiasis - Total
0 5. No. of confirmed acute cases - Total
6. No. of chronic clinically diagnosed
cases - Total
Section F. _________________________
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
 ___JANUARY_____ YEAR: ____2020___

M1
AGPAKO__________________________
_________________________
_________________________

BRGY
________________________
________________________
r submission to RHU/MHC

Services and Deworming for Women of Reproductive Age

Total A3. Deworming Services SES Total

Col. 3) (Col. 1) (Col. 2) (Col. 3)

NHTS Non-NHTS
1. No. of women 20-49 years old given 2 doses of
15 deworming drugs - Total
0 0 0
15
0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
on B. Maternal Care and Services
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

a. Number of pregnant women seen in the

first trimester who have normal BMI -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of pregnant women seen in the first
trimester who have low BMI - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

7. No. of pregnant women given iodine

capsules – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
8. No. of pregnant women given one dose
of deworming tablet - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
9. No. of pregnant women screened for
syphilis - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
10. No. of pregnant women tested positive
for syphilis - Total

0 0 0 0
 • NHTS 0
• Non-NHTS 0
11. No. of pregnant women screened for
Hepatitis B - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
18. No. of deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
19. No. of live births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20a. No. of live births with normal birth
weight - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20b. No. of live births with low birth weight
- Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
20c. No. of live births with unknown birth
weight- Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
21. No. of deliveries attended by skilled
health professionals - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col 3)  (Col. 4)
rks Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

24a. No. of deliveries in public health

facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
24b. No. of deliveries in private health
facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
25. No. of non-facility-based deliveries -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
26a. No. of vaginal deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
26b. No. of deliveries by cesarean
section – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
27a. No. of full-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
27b. No. of pre-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B3. Postpartum and Newborn Care
28. No. of postpartum women together
with their newborn who completed at
least 2 postpartum check-ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
 29. No. of postpartum women who
completed iron with folic acid
supplementation - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
30. No. of postpartum women with
Vitamin A supplementation – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
ction C. Child Care and Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)

epB 3 - Total 0 0 0 11. PCV 1 - Total 0 0

0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 12. PCV 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 13. PCV 3 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 14. MMR 1 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
0 0 0 15. MMR 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
1 (November) - Total 0 0 0 20. Td, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
e 1 (November) - Total 0 0 0 21. MR, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

34. Children 12-23 mos. who completed

1 mos. old seen - Total
MNP supplementation - Total
0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
 1 mos. given 1 dose of
35. Children 0-59 mos. seen - Total
100,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos seen - Total 0 0 0 36. Stunted - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos. old given 2
37. Wasted - Total
tamin A 200,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
1 months old who completed
38. Overweight/Obese - Total
lementation - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS

2-23 mos. seen - Total 39. Normal - Total

0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col. 1) (Col 2) (Col 3)

y/o dewormed (2 doses) - 43. Adolescents, 10-19 y/o dewormed

0 0 0 (2 doses) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

ren 12-59 mos. old 50. Diarrhea cases 0-59 mos. received
itamin A - Total 0 0 0 ORS w/ zinc - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old seen 51. Pneumonia cases 0-59 mos. old
0 0 0 seen - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old 52. Pneumonia cases 0-59 mos. old
ORS - Total 0 0 0 completed treatment - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
 To be submitted Quarterly
ous Disease Prevention and Control Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
miasis Prevention and Control E2. Schistosomiasis Prevention and Control (Con't.)
le 5-65 y/o who ingested 7. No. confirmed chronic cases - Total
- Total 0
nts seen - Total 0 8. No. of confirmed cases (acute and
ected cases seen 0 chronic) - Total
clinically diagnosed cases - 9. No. of cases treated - Total
0
rmed acute cases - Total 0 10. No. of confirmed chronic cases
nic clinically diagnosed referred to a hospital facility - Total
al 0
_________________________________________
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
M1
RGY
Total

(Col. 3)

New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
 0 0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0 0
0
0
0 0
0
0
0 0
0
0
 0 0
0
0

Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
 Total
(Col 4)

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Total
(Col 4)
0
0
0
0
0
0

0
0
0
 0
0
0
0
0
0

0
0
0

0
0
0

0
0
0
Total
(Col 4)

0
0
0

0
0
0

0
0
0

0
0
0
 Total
(Col 4)
't.)

Total
(Col 4)
 FHSIS REPORT for the MONTH: __MAY YEAR: 202
Name of Barangay: 24 A
Name of BHS: 24 A
Name of Municipality: GINGOOG CITY
Name of Province: MISAMIS ORIENTAL
Projected Population of the Year 3688
For submission to RHU/MHC

Section A. Family Planning Services and Dewor

A1. Modern FP Unmet Need Age Total

(Col. 1) (Col. 2) (Col. 3)

10-14 15-19 20-49
1. No. of WRA with unmet
need for modern FP - Total 15 20
35
• NHTS 5 5 10
• Non-NHTS 10 15 25
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
a. Female Sterilization/ BTL -
Total 0 0 29 29 0 0 0 0 0
• NHTS 0 0 3 3 0 0 0 0 0
• Non-NHTS 0 0 26 26 0 0 0 0 0
b. Male Sterilization/ NSV-Total 0 0 1 1 0 0 0 0 0
• NHTS 0 0 0 0 0 0 0 0 0
• Non-NHTS 0 0 1 1 0 0 0 0 0
c. Condom - Total 0 0 23 23 0 0 0 0 0
• NHTS 0 0 2 2 0 0 0 0 0
• Non-NHTS 0 0 21 21 0 0 0 0 0
d. Pills - Total 0 20 196 216 0 0 0 0 0
• NHTS 0 2 32 34 0 0 0 0 0
• Non-NHTS 0 18 165 183 0 0 0 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
 d.1 Pills-POP - Total 0 2 10 12 0 0 91 91 0
• NHTS 0 0 0 0 0 0 56 56 0
• Non-NHTS 0 2 10 12 0 0 35 35 0
d.2 Pills-COC - Total 0 18 183 201 0 0 21 21 0
• NHTS 0 2 30 32 0 0 14 14 0
• Non-NHTS 0 16 153 169 0 0 7 7 0
e. Injectables (DMPA/ POI) -
Total 0 5 15 20 0 0 7 7 0
• NHTS 0 1 4 5 0 0 0 0 0
• Non-NHTS 0 4 11 15 0 0 0 0 0
f. Implant - Total 0 0 4 4 0 0 0 0 0
• NHTS 0 0 0 0 0 0 0 0 0
• Non-NHTS 0 0 4 4 0 0 0 0 0
g. IUD (IUD-I and IUD-PP) -
Total 0 0 21 21 0 0 0 0 0
• NHTS 0 0 4 4 0 0 0 0 0
• Non-NHTS 0 0 17 17 0 0 0 0 0
g.1 IUD-I- Total 0 0 20 20 0 0 0 0 0
• NHTS 0 0 4 4 0 0 0 0 0
• Non-NHTS 0 0 16 16 0 0 0 0 0
g.2 IUD-PP - Total 0 0 1 1 0 0 0 0 0
• NHTS 0 0 0 0 0 0 0 0 0
• Non-NHTS 0 0 1 1 0 0 0 0 0
h. NFP-LAM - Total 0 1 4 5 0 1 0 1 0
• NHTS 0 1 1 2 0 0 0 0 0
• Non-NHTS 0 0 3 3 0 1 0 1 0
i. NFP-BBT - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0 0 0 0 0 0 0 0
• Non-NHTS 0 0 0 0 0 0 0 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
j. NFP-CMM - Total 0 0 75 75 0 0 0 0 0
• NHTS 0 0 3 3 0 0 0 0 0
• Non-NHTS 0 0 72 72 0 0 0 0 0
k. NFP-STM - Total 0 0 23 23 0 0 0 0 0
• NHTS 0 0 0 0 0 0 0 0 0
• Non-NHTS 0 0 23 23 0 0 0 0 0
l. NFP-SDM - Total 0 0 125 125 0 0 0 0 0
• NHTS 0 0 10 10 0 0 0 0 0
• Non-NHTS 0 0 115 115 0 0 0 0 0
m. Total Current Users 0 37 523 560 0 0 0 0 0
• NHTS 0 7 57 64 0 0 0 0 0
• Non-NHTS 0 30 466 496 0 0 0 0 0
Section B. Maternal Care
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
1. No. of pregnant women w/
at least 4 prenatal check-
ups - Total 0 0 3 3
• NHTS 0 0 0 0
• Non-NHTS 0 0 3 3
2. No. of pregnant women
assessed of their nutritional
status during the 1st tri. -Total 0 0 3 3
• NHTS 0 0 0 0
• Non-NHTS 0 0 3 3
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
c. No. of pregnant women
seen in the first trimester
who have high BMI - Total 0 0 0 0
• NHTS 0 0 0 0
• Non-NHTS 0 0 0 0
3. No. of pregnant women for
the first time given 2 doses of
Td vaccination - Total 0 0 0 0
• NHTS 0 0 0 0
• Non-NHTS 0 0 0 0
4. No. of pregnant women for
the 2nd or more times given
at least 3 doses of Td
vaccination (Td2 Plus) - Total
0 0 3 3
• NHTS 0 0 0 0
• Non-NHTS 0 0 3 3
5. No. of pregnant women who
completed the dose of iron
with folic acid
supplementation - Total 0 0 3 3
 • NHTS 0 0 0 0
• Non-NHTS 0 0 3 3
6. No. of pregnant women who
completed doses of calcium
carbonate supplementation -
Total 0 0 0 0
• NHTS 0 0 0 0
• Non-NHTS 0 0 0 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
12. No. of pregnant women
tested positive for Hepatitis
B - Total 0 0 0 0
• NHTS 0 0 0 0
• Non-NHTS 0 0 0 0
13. No. of pregnant women
screened for HIV - Total 0 0 0 0
• NHTS 0 0 0 0
• Non-NHTS 0 0 0 0
14. No. of pregnant women
tested for CBC or Hgb&Hct
count - Total 0 0 0 0
• NHTS 0 0 0 0
• Non-NHTS 0 0 0 0
15. No. of pregnant women
tested for CBC or Hgb&Hct
count diagnosed with
anemia - Total 0 0 0 0
• NHTS 0 0 0 0
• Non-NHTS 0 0 0 0
16. No. of pregnant women
screened for gestational
diabetes – Total 0 0 0 0
• NHTS 0 0 0 0
• Non-NHTS 0 0 0 0
17.   No. of pregnant women
tested positive for
gestational diabetes – Total 0 0 0 0
• NHTS 0 0 0 0
• Non-NHTS 0 0 0 0
Indicators Age Total Remarks
(Col 3)  (Col. 4)
 Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
a. No. of deliveries attended
by a doctor - Total 0 0 3 3
• NHTS 0 0 0 0
• Non-NHTS 0 0 3 3
b. No. of deliveries attended
by a nurse – Total 0 0 0 0
• NHTS 0 0 0 0
• Non-NHTS 0 0 0 0
c. No. of deliveries attended
by midwives - Total 0 0 0 0
• NHTS 0 0 0 0
• Non-NHTS 0 0 0 0
22. No. of deliveries attended by
non-skilled health
professionals - Total 0 0 0 0
• NHTS 0 0 0 0
• Non-NHTS 0 0 0 0
a. No. of deliveries attended
by Hilot/TBA - Total 0 0 0 0
• NHTS 0 0 0 0
• Non-NHTS 0 0 0 0
b. No. of deliveries attended
by others - Total 0 0 0 0
• NHTS 0 0 0 0
• Non-NHTS 0 0 0 0
23. No. of health facility-based
deliveries - Total 0 0 3 3
• NHTS 0 0 0 0
• Non-NHTS 0 0 3 3
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
27c. No. of fetal deaths - Total

0 0 0 0
• NHTS 0 0 0 0
• Non-NHTS 0 0 0 0
27d. No. of abortion/
miscarriage - Total
0 0 0 0
• NHTS 0 0 0 0
• Non-NHTS 0 0 0 0

Section C. Child Care a

Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
C1. Immunization Services
1. CPAB - Total 1 3 4 6. DPT-HiB-HepB 3 - Total
• NHTS 0 0 0 • NHTS
• Non-NHTS 1 3 4 • Non-NHTS
2. BCG - Total 1 3 4 7. OPV 1 - Total
• NHTS 0 0 0 • NHTS
• Non-NHTS 1 3 4 • Non-NHTS
3. HepB, within 24 hours. - Total 1 3 4 8. OPV 2 - Total
• NHTS 0 0 0 • NHTS
• Non-NHTS 1 1 2 • Non-NHTS
4. DPT-HiB-HepB 1 - Total 1 1 2 9. OPV 3 - Total
• NHTS 0 0 0 • NHTS
• Non-NHTS 1 1 2 • Non-NHTS
5. DPT-HiB-HepB 2 - Total 2 2 4 10. IPV - Total
• NHTS 0 0 0 • NHTS
• Non-NHTS 2 2 4 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
16. FIC - Total 1 5 6 18. Td, Grade 1 (November) - Total
• NHTS 0 0 0 • NHTS
• Non-NHTS 1 5 6 • Non-NHTS
17. CIC - Total 0 0 0 19. MR, Grade 1 (November) - Total
• NHTS 0 0 0 • NHTS
• Non-NHTS 0 0 0 • Non-NHTS
C2. Nutrition Services
22. Newborns initiated on breastfeeding
immediately after birth lasting to 90 mins - 28. Infants 6-11 mos. old seen - Total
Total 1 2 3
• NHTS 0 0 0 • NHTS
• Non-NHTS 0 0 0 • Non-NHTS
23. Preterm/LBW infants given iron 29. Infants 6-11 mos. given 1 dose of
supplementation - Total 0 0 0 Vitamin A 100,000 I.U. - Total
• NHTS 0 0 0 • NHTS
• Non-NHTS 0 0 0 • Non-NHTS
24. Infants 6 mos. old seen - Total 3 5 8 30. Children 12-59 mos seen - Total
• NHTS 0 0 0 • NHTS
• Non-NHTS 0 0 0 • Non-NHTS
25. Infants exclusively breastfed until 6th month - 31. Children 12-59 mos. old given 2
Total 3 5 8 doses of Vitamin A 200,000 I.U. - Total
• NHTS 0 0 0 • NHTS
• Non-NHTS 0 0 0 • Non-NHTS
26. Infants 6 mos. old initiated to complementary 32. Infant 6-11 months old who completed
feeding with continued breastfeeding - Total 0 0 0 MNP supplementation - Total
• NHTS 0 0 0 • NHTS
• Non-NHTS 0 0 0 • Non-NHTS
27. Infants 6 mos. old initiated to complementary
feeding but no longer or never been breastfed 33. Children 12-23 mos. seen - Total
- Total 0 0 0
• NHTS 0 0 0 • NHTS
• Non-NHTS 0 0 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
0
40. 1-19 y/o given 2 doses of deworming drug - 42. SAC, 5-9 y/o dewormed (2 doses) -
Total 0 0 0 Total
• NHTS 0 0 0 • NHTS
• Non-NHTS 0 0 0 • Non-NHTS
41. PSAC, 1-4 y/o dewormed (2 doses) - Total 0 0 0
• NHTS 0 0 0
• Non-NHTS 0 0 0
0
44. Sick Infants 6-11 mos. old seen - Total 47. Sick Children 12-59 mos. old
0 0 0 received Vitamin A - Total
• NHTS 0 0 0 • NHTS
• Non-NHTS 0 0 0 • Non-NHTS
45. Sick Infants 6-11 mos. old received 48. Diarrhea cases 0-59 months old seen
Vitamin A - Total 0 0 0 - Total
• NHTS 0 0 0 • NHTS
• Non-NHTS 0 0 0 • Non-NHTS
49. Diarrhea cases 0-59 months old
46. Sick Children 12-59 mos. old seen - Total
0 0 0 received ORS - Total
• NHTS 0 0 0 • NHTS
• Non-NHTS 0 0 0 • Non-NHTS
 To be submitted Qua
Section E. Infectious Disease Preven
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
E1. Filariasis Prevention and Control E2. Schistosomiasis Prevention and Contro
1. No. of individual examined for lymphatic 1. No. of people 5-65 y/o who ingested
filariasis - Total 0 0 0 MDA drugs - Total
2. No. of individual examined found positive for 2. No. of patients seen - Total
lymphatic filariasis - Total 0 0 0 3. No. of suspected cases seen
3. No. of lymphatic filariasis cases examined with 4. No. acute clinically diagnosed cases -
manifestation of either lymphedema,hydrocele, Total
elephantiasis - Total
0 0 0 5. No. of confirmed acute cases - Total
6. No. of chronic clinically diagnosed
cases - Total
Section F. _________________________
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)

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

ARI 6 8 14
URTI 10 3 13
SKIN LESION 3 2 5
MYALGIA 2 1 3
COUGH AND COLDS 16 11 27
HYPERTENSION 102 120 222
DIABETIS 15 20 35
ASTHMATIC 1 0 1
DIARRHEA 5 7 12
WOUND 5 3 8
BOILS 3 2 5
FEVER 6 5 11
 __MAY YEAR: 2022_

OG CITY M1
BRGY
S ORIENTAL

r submission to RHU/MHC

Services and Deworming for Women of Reproductive Age

Total A3. Deworming Services SES Total

Col. 3) (Col. 1) (Col. 2) (Col. 3)

NHTS Non-NHTS
1. No. of women 20-49 years old given 2 doses of
35 deworming drugs - Total
0 0 0
10
25
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19

0 0 0 0 0 2 2 0 0 27 27 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 1 1 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 1 1 0 0 0 0 0 0
0 0 0 0 0 20 20 0 0 3 3 0 0
0 0 0 0 0 2 2 0 0 2 2 0 0
0 0 0 0 0 18 18 0 0 1 1 0 0
0 0 0 0 0 15 15 0 20 181 201 0 0
0 0 0 0 0 5 5 0 2 27 29 0 0
0 0 0 0 0 10 10 0 18 154 172 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
 0 260 260 0 0 0 0 0 2 10 12 0 0
0 160 160 0 0 0 0 0 0 0 0 0 0
0 100 100 0 0 0 0 0 2 10 12 0 0
0 60 60 0 2 83 85 0 16 100 116 0 0
0 40 40 0 0 20 20 0 2 10 12 0 0
0 20 20 0 0 63 63 0 14 90 104 0 0

0 20 20 0 0 0 0 0 5 42 47 0 0
0 0 0 0 0 0 0 0 1 5 6 0 0
0 0 0 0 0 0 0 0 4 37 41 0 0
0 0 0 0 0 1 1 0 0 3 3 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 1 1 0 0 3 3 0 0

0 0 0 0 0 4 4 0 0 17 17 0 0
0 0 0 0 0 0 0 0 0 4 4 0 0
0 0 0 0 0 4 4 0 0 17 17 0 0
0 0 0 0 0 0 0 0 0 20 20 0 0
0 0 0 0 0 0 0 0 0 4 4 0 0
0 0 0 0 0 0 0 0 0 16 16 0 0
0 0 0 0 0 0 0 0 0 1 1 0 0
0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 1 1 0 0
0 11 11 0 0 0 0 0 1 15 16 0 0
0 5 5 0 0 0 0 0 2 2 0 0
0 6 6 0 0 0 0 1 13 14 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 385 10 395 0 1888 65 1953 0 0
0 0 0 0 238 3 241 0 1167 3 1170 0 0
0 0 0 0 147 7 154 0 721 62 783 0 0
0 0 0 0 91 5 96 0 446 18 464 0 0
0 0 0 0 56 0 56 0 275 0 275 0 0
0 0 0 0 35 5 40 0 171 18 189 0 0
0 0 0 0 21 20 41 0 104 105 209 0 0
0 0 0 0 14 3 17 0 67 7 74 0 0
0 0 0 0 7 17 24 0 37 98 135 0 0
 0 0 0 0 7 20 27 0 30 503 533 0 0
0 0 0 0 0 0 0 0 7 20 27 0 0
0 0 0 0 0 0 0 0 23 483 506 0 0
on B. Maternal Care and Services
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

a. Number of pregnant women seen in the

first trimester who have normal BMI -
Total 0 0 3 3
• NHTS 0 0 0 0
• Non-NHTS 0 0 3 3
b. No. of pregnant women seen in the first
trimester who have low BMI - Total
0 0 0 0
• NHTS 0 0 0 0
• Non-NHTS 0 0 0 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

7. No. of pregnant women given iodine

capsules – Total
0 0 0 0
• NHTS 0 0 0 0
• Non-NHTS 0 0 0 0
8. No. of pregnant women given one dose
of deworming tablet - Total
0 0 0 0
• NHTS 0 0 0 0
• Non-NHTS 0 0 0 0
9. No. of pregnant women screened for
syphilis - Total

0 0 0 0
• NHTS 0 0 0 0
• Non-NHTS 0 0 0 0
10. No. of pregnant women tested positive
for syphilis - Total

0 0 0 0
 • NHTS 0 0 0 0
• Non-NHTS 0 0 0 0
11. No. of pregnant women screened for
Hepatitis B - Total

0 0 3 3
• NHTS 0 0 0 0
• Non-NHTS 0 0 3 3
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
18. No. of deliveries – Total

0 0 0 0
• NHTS 0 0 0 0
• Non-NHTS 0 0 0 0
19. No. of live births – Total
0 0 0 0
• NHTS 0 0 0 0
• Non-NHTS 0 0 0 0
20a. No. of live births with normal birth
weight - Total
0 0 0 0
• NHTS 0 0 0 0
• Non-NHTS 0 0 0 0
20b. No. of live births with low birth weight
- Total

0 0 0 0
• NHTS 0 0 0 0
• Non-NHTS 0 0 0 0
20c. No. of live births with unknown birth
weight- Total
0 0 0 0
• NHTS 0 0 0 0
• Non-NHTS 0 0 0 0
21. No. of deliveries attended by skilled
health professionals - Total
0 0 0 0
• NHTS 0 0 0 0
• Non-NHTS 0 0 0 0
rks Indicators Age Total Remarks
4) (Col 3)  (Col. 4)
rks Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

24a. No. of deliveries in public health

facility - Total 0 0 3 3
• NHTS 0 0 0 0
• Non-NHTS 0 0 3 3
24b. No. of deliveries in private health
facility - Total 0 0 0 0
• NHTS 0 0 0 0
• Non-NHTS 0 0 0 0
25. No. of non-facility-based deliveries -
Total 0 0 0 0
• NHTS 0 0 0 0
• Non-NHTS 0 0 0 0
26a. No. of vaginal deliveries – Total

0 0 3 3
• NHTS 0 0 0 0
• Non-NHTS 0 0 3 3
26b. No. of deliveries by cesarean
section – Total 0 0 0 0
• NHTS 0 0 0 0
• Non-NHTS 0 0 0 0
27a. No. of full-term births – Total
0 0 3 3
• NHTS 0 0 0 0
• Non-NHTS 0 0 3 3
27b. No. of pre-term births – Total
0 0 0 0
• NHTS 0 0 0 0
• Non-NHTS 0 0 0 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B3. Postpartum and Newborn Care
28. No. of postpartum women together
with their newborn who completed at
least 2 postpartum check-ups - Total
0 0 3 3
• NHTS 0 0 0 0
• Non-NHTS 0 0 3 3
 29. No. of postpartum women who
completed iron with folic acid
supplementation - Total 0 0 3 3
• NHTS 0 0 0 0
• Non-NHTS 0 0 3 3
30. No. of postpartum women with
Vitamin A supplementation – Total 0 0 0 0
• NHTS 0 0 0 0
• Non-NHTS 0 0 0 0
ction C. Child Care and Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)

epB 3 - Total 2 3 5 11. PCV 1 - Total 1 1

0 0 0 • NHTS 0 0
TS 2 3 5 • Non-NHTS 1 1
al 1 1 2 12. PCV 2 - Total 2 2
0 0 0 • NHTS 0 0
TS 1 1 2 • Non-NHTS 2 2
al 2 2 4 13. PCV 3 - Total 2 3
0 0 0 • NHTS 0 0
TS 2 2 4 • Non-NHTS 2 3
al 2 3 5 14. MMR 1 - Total 1 5
0 0 0 • NHTS 0 2
TS 2 3 5 • Non-NHTS 1 3
2 3 5 15. MMR 2 - Total 4 2
0 0 0 • NHTS 0 0
TS 2 3 5 • Non-NHTS 4 2
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
1 (November) - Total 0 0 0 20. Td, Grade 7 (November) - Total 0 0
0 0 0 • NHTS 0 0
TS 0 0 0 • Non-NHTS 0 0
e 1 (November) - Total 0 0 0 21. MR, Grade 7 (November) - Total 0 0
0 0 0 • NHTS 0 0
TS 0 0 0 • Non-NHTS 0 0

34. Children 12-23 mos. who completed

1 mos. old seen - Total
MNP supplementation - Total
0 0 0 0 0
0 0 0 • NHTS 0 0
TS 0 0 0 • Non-NHTS 0 0
 1 mos. given 1 dose of
35. Children 0-59 mos. seen - Total
100,000 I.U. - Total 0 0 0 0 0
0 0 0 • NHTS 0 0
TS 0 0 0 • Non-NHTS 0 0
2-59 mos seen - Total 0 0 0 36. Stunted - Total 0 0
0 0 0 • NHTS 0 0
TS 0 0 0 • Non-NHTS 0 0
2-59 mos. old given 2
37. Wasted - Total
tamin A 200,000 I.U. - Total 0 0 0 0 0
0 0 0 • NHTS 0 0
TS 0 0 0 • Non-NHTS 0 0
1 months old who completed
38. Overweight/Obese - Total
lementation - Total 0 0 0 0 0
0 0 0 • NHTS 0 0
TS 0 0 0 • Non-NHTS 0 0

2-23 mos. seen - Total 39. Normal - Total

0 0 0 0 0
0 0 0 • NHTS 0 0
TS 0 0 0 • Non-NHTS 0 0
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col. 1) (Col 2) (Col 3)

y/o dewormed (2 doses) - 43. Adolescents, 10-19 y/o dewormed

0 0 0 (2 doses) - Total 0 0
0 0 0 • NHTS 0 0
TS 0 0 0 • Non-NHTS 0 0

ren 12-59 mos. old 50. Diarrhea cases 0-59 mos. received
itamin A - Total 0 0 0 ORS w/ zinc - Total 0 0
0 0 0 • NHTS 0 0
TS 0 0 0 • Non-NHTS 0 0
ases 0-59 months old seen 51. Pneumonia cases 0-59 mos. old
0 0 0 seen - Total 0 0
0 0 0 • NHTS 0 0
TS 0 0 0 • Non-NHTS 0 0
ases 0-59 months old 52. Pneumonia cases 0-59 mos. old
ORS - Total 0 0 0 completed treatment - Total 0 0
0 0 0 • NHTS 0 0
TS 0 0 0 • Non-NHTS 0 0
 To be submitted Quarterly
ous Disease Prevention and Control Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
miasis Prevention and Control E2. Schistosomiasis Prevention and Control (Con't.)
le 5-65 y/o who ingested 7. No. confirmed chronic cases - Total
- Total 0 0 0 0 0
nts seen - Total 0 0 0 8. No. of confirmed cases (acute and
ected cases seen 0 0 0 chronic) - Total 0 0
nically diagnosed cases - 9. No. of cases treated - Total
0 0 0 0 0
rmed acute cases - Total 0 0 0 10. No. of confirmed chronic cases
nic clinically diagnosed referred to a hospital facility - Total
al 0 0 0 0 0
_________________________________________
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)

(Col. 1)
M1
RGY
Total

(Col. 3)

New Acceptors
(Present Month)

(Col. 7)
20-49 Total

0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
4 4
0 0
4 4
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
 2 2
0 0
0 0
2 2
0 0
0 0

0 0
0 0
0 0
0 0
0 0
0 0

0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
 0 0
0 0
0 0

Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
 Total
(Col 4)

2
0
2
4
0
4
5
0
5
6
2
4
6
0
6
Total
(Col 4)
0
0
0
0
0
0

0
0
0
 0
0
0
0
0
0

0
0
0

0
0
0

0
0
0
Total
(Col 4)

0
0
0

0
0
0

0
0
0

0
0
0
 Total
(Col 4)
't.)

Total
(Col 4)
 FHSIS REPORT for the MONTH: ___JANUARY_____
Name of Barangay: _____TAGPAKO_________
Name of BHS: _______________________
Name of Municipality/City: _______________________
Name of Province: ________________________
Projected Population of the Year: _______________________
For submission to RHU/MHC

Section A. Family Planning Services and Dewor

A1. Modern FP Unmet Need Age Total

(Col. 1) (Col. 2) (Col. 3)

10-14 15-19 20-49
1. No. of WRA with unmet
need for modern FP - Total 5 5 5
15
• NHTS 5 5 5 15
• Non-NHTS 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
a. Female Sterilization/ BTL - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
b. Male Sterilization/ NSV-Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
c. Condom - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d. Pills - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
 d.1 Pills-POP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d.2 Pills-COC - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
e. Injectables (DMPA/ POI) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
f. Implant - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g. IUD (IUD-I and IUD-PP) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.1 IUD-I- Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.2 IUD-PP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
h. NFP-LAM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
i. NFP-BBT - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
j. NFP-CMM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
k. NFP-STM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
l. NFP-SDM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
m. Total Current Users 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
Section B. Maternal Care
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
1. No. of pregnant women w/
at least 4 prenatal check-
ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
2. No. of pregnant women
assessed of their nutritional
status during the 1st tri. -Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
c. No. of pregnant women
seen in the first trimester
who have high BMI - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
3. No. of pregnant women for
the first time given 2 doses of
Td vaccination - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
4. No. of pregnant women for
the 2nd or more times given
at least 3 doses of Td
vaccination (Td2 Plus) - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
5. No. of pregnant women who
completed the dose of iron
with folic acid
supplementation - Total 0 0 0 0
 • NHTS 0
• Non-NHTS 0
6. No. of pregnant women who
completed doses of calcium
carbonate supplementation -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
12. No. of pregnant women
tested positive for Hepatitis
B - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
13. No. of pregnant women
screened for HIV - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
14. No. of pregnant women
tested for CBC or Hgb&Hct
count - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
15. No. of pregnant women
tested for CBC or Hgb&Hct
count diagnosed with
anemia - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
16. No. of pregnant women
screened for gestational
diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
17.   No. of pregnant women
tested positive for
gestational diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col 3)  (Col. 4)
 Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
a. No. of deliveries attended
by a doctor - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by a nurse – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
c. No. of deliveries attended
by midwives - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
22. No. of deliveries attended by
non-skilled health
professionals - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
a. No. of deliveries attended
by Hilot/TBA - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by others - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
23. No. of health facility-based
deliveries - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
27c. No. of fetal deaths - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
27d. No. of abortion/
miscarriage - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0

Section C. Child Care a

Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
C1. Immunization Services
1. CPAB - Total 0 0 0 6. DPT-HiB-HepB 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
2. BCG - Total 0 0 0 7. OPV 1 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
3. HepB, within 24 hours. - Total 0 0 0 8. OPV 2 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
4. DPT-HiB-HepB 1 - Total 0 0 0 9. OPV 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
5. DPT-HiB-HepB 2 - Total 0 0 0 10. IPV - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
16. FIC - Total 0 0 0 18. Td, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
17. CIC - Total 0 0 0 19. MR, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
C2. Nutrition Services
22. Newborns initiated on breastfeeding
immediately after birth lasting to 90 mins - 28. Infants 6-11 mos. old seen - Total
Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
23. Preterm/LBW infants given iron 29. Infants 6-11 mos. given 1 dose of
supplementation - Total 0 0 0 Vitamin A 100,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
24. Infants 6 mos. old seen - Total 0 0 0 30. Children 12-59 mos seen - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
25. Infants exclusively breastfed until 6th month - 31. Children 12-59 mos. old given 2
Total 0 0 0 doses of Vitamin A 200,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
26. Infants 6 mos. old initiated to complementary 32. Infant 6-11 months old who completed
feeding with continued breastfeeding - Total 0 0 0 MNP supplementation - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
27. Infants 6 mos. old initiated to complementary
feeding but no longer or never been breastfed 33. Children 12-23 mos. seen - Total
- Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
0
40. 1-19 y/o given 2 doses of deworming drug - 42. SAC, 5-9 y/o dewormed (2 doses) -
Total 0 0 0 Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
41. PSAC, 1-4 y/o dewormed (2 doses) - Total 0 0 0
• NHTS 0
• Non-NHTS 0
0
44. Sick Infants 6-11 mos. old seen - Total 47. Sick Children 12-59 mos. old
0 0 0 received Vitamin A - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
45. Sick Infants 6-11 mos. old received 48. Diarrhea cases 0-59 months old seen
Vitamin A - Total 0 0 0 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
49. Diarrhea cases 0-59 months old
46. Sick Children 12-59 mos. old seen - Total
0 0 0 received ORS - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
 To be submitted Qua
Section E. Infectious Disease Preven
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
E1. Filariasis Prevention and Control E2. Schistosomiasis Prevention and Contro
1. No. of individual examined for lymphatic 1. No. of people 5-65 y/o who ingested
filariasis - Total 0 MDA drugs - Total
2. No. of individual examined found positive for 2. No. of patients seen - Total
lymphatic filariasis - Total 0 3. No. of suspected cases seen
3. No. of lymphatic filariasis cases examined with 4. No. acute clinically diagnosed cases -
manifestation of either lymphedema,hydrocele, Total
elephantiasis - Total
0 5. No. of confirmed acute cases - Total
6. No. of chronic clinically diagnosed
cases - Total
Section F. _________________________
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
 ___JANUARY_____ YEAR: ____2020___

M1
AGPAKO__________________________
_________________________
_________________________

BRGY
________________________
________________________
r submission to RHU/MHC

Services and Deworming for Women of Reproductive Age

Total A3. Deworming Services SES Total

Col. 3) (Col. 1) (Col. 2) (Col. 3)

NHTS Non-NHTS
1. No. of women 20-49 years old given 2 doses of
15 deworming drugs - Total
0 0 0
15
0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
on B. Maternal Care and Services
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

a. Number of pregnant women seen in the

first trimester who have normal BMI -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of pregnant women seen in the first
trimester who have low BMI - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

7. No. of pregnant women given iodine

capsules – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
8. No. of pregnant women given one dose
of deworming tablet - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
9. No. of pregnant women screened for
syphilis - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
10. No. of pregnant women tested positive
for syphilis - Total

0 0 0 0
 • NHTS 0
• Non-NHTS 0
11. No. of pregnant women screened for
Hepatitis B - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
18. No. of deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
19. No. of live births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20a. No. of live births with normal birth
weight - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20b. No. of live births with low birth weight
- Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
20c. No. of live births with unknown birth
weight- Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
21. No. of deliveries attended by skilled
health professionals - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col 3)  (Col. 4)
rks Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

24a. No. of deliveries in public health

facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
24b. No. of deliveries in private health
facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
25. No. of non-facility-based deliveries -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
26a. No. of vaginal deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
26b. No. of deliveries by cesarean
section – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
27a. No. of full-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
27b. No. of pre-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B3. Postpartum and Newborn Care
28. No. of postpartum women together
with their newborn who completed at
least 2 postpartum check-ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
 29. No. of postpartum women who
completed iron with folic acid
supplementation - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
30. No. of postpartum women with
Vitamin A supplementation – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
ction C. Child Care and Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)

epB 3 - Total 0 0 0 11. PCV 1 - Total 0 0

0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 12. PCV 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 13. PCV 3 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 14. MMR 1 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
0 0 0 15. MMR 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
1 (November) - Total 0 0 0 20. Td, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
e 1 (November) - Total 0 0 0 21. MR, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

34. Children 12-23 mos. who completed

1 mos. old seen - Total
MNP supplementation - Total
0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
 1 mos. given 1 dose of
35. Children 0-59 mos. seen - Total
100,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos seen - Total 0 0 0 36. Stunted - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos. old given 2
37. Wasted - Total
tamin A 200,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
1 months old who completed
38. Overweight/Obese - Total
lementation - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS

2-23 mos. seen - Total 39. Normal - Total

0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col. 1) (Col 2) (Col 3)

y/o dewormed (2 doses) - 43. Adolescents, 10-19 y/o dewormed

0 0 0 (2 doses) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

ren 12-59 mos. old 50. Diarrhea cases 0-59 mos. received
itamin A - Total 0 0 0 ORS w/ zinc - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old seen 51. Pneumonia cases 0-59 mos. old
0 0 0 seen - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old 52. Pneumonia cases 0-59 mos. old
ORS - Total 0 0 0 completed treatment - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
 To be submitted Quarterly
ous Disease Prevention and Control Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
miasis Prevention and Control E2. Schistosomiasis Prevention and Control (Con't.)
le 5-65 y/o who ingested 7. No. confirmed chronic cases - Total
- Total 0
nts seen - Total 0 8. No. of confirmed cases (acute and
ected cases seen 0 chronic) - Total
clinically diagnosed cases - 9. No. of cases treated - Total
0
rmed acute cases - Total 0 10. No. of confirmed chronic cases
nic clinically diagnosed referred to a hospital facility - Total
al 0
_________________________________________
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
M1
RGY
Total

(Col. 3)

New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
 0 0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0 0
0
0
0 0
0
0
0 0
0
0
 0 0
0
0

Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
 Total
(Col 4)

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Total
(Col 4)
0
0
0
0
0
0

0
0
0
 0
0
0
0
0
0

0
0
0

0
0
0

0
0
0
Total
(Col 4)

0
0
0

0
0
0

0
0
0

0
0
0
 Total
(Col 4)
't.)

Total
(Col 4)
BRGY

FHSIS REPORT for the MONTH: ___JANUARY_____

Name of Barangay: _____TAGPAKO_________
Name of BHS: _______________________
Name of Municipality/City: _______________________
Name of Province: ________________________
Projected Population of the Year: _______________________
For submission to RHU/MHC

Section A. Family Planning Services and Dewor

A1. Modern FP Unmet Need Age Total

(Col. 1) (Col. 2) (Col. 3)

10-14 15-19 20-49
1. No. of WRA with unmet
need for modern FP - Total 5 5 5
15
• NHTS 5 5 5 15
• Non-NHTS 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
a. Female Sterilization/ BTL - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
b. Male Sterilization/ NSV-Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
c. Condom - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d. Pills - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
 d.1 Pills-POP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d.2 Pills-COC - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
e. Injectables (DMPA/ POI) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
f. Implant - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g. IUD (IUD-I and IUD-PP) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.1 IUD-I- Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.2 IUD-PP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
h. NFP-LAM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
i. NFP-BBT - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
j. NFP-CMM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
k. NFP-STM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
l. NFP-SDM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
m. Total Current Users 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
Section B. Maternal Care
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
1. No. of pregnant women w/
at least 4 prenatal check-
ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
2. No. of pregnant women
assessed of their nutritional
status during the 1st tri. -Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
c. No. of pregnant women
seen in the first trimester
who have high BMI - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
3. No. of pregnant women for
the first time given 2 doses of
Td vaccination - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
4. No. of pregnant women for
the 2nd or more times given
at least 3 doses of Td
vaccination (Td2 Plus) - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
5. No. of pregnant women who
completed the dose of iron
with folic acid
supplementation - Total 0 0 0 0
 • NHTS 0
• Non-NHTS 0
6. No. of pregnant women who
completed doses of calcium
carbonate supplementation -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
12. No. of pregnant women
tested positive for Hepatitis
B - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
13. No. of pregnant women
screened for HIV - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
14. No. of pregnant women
tested for CBC or Hgb&Hct
count - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
15. No. of pregnant women
tested for CBC or Hgb&Hct
count diagnosed with
anemia - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
16. No. of pregnant women
screened for gestational
diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
17.   No. of pregnant women
tested positive for
gestational diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col 3)  (Col. 4)
 Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
a. No. of deliveries attended
by a doctor - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by a nurse – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
c. No. of deliveries attended
by midwives - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
22. No. of deliveries attended by
non-skilled health
professionals - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
a. No. of deliveries attended
by Hilot/TBA - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by others - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
23. No. of health facility-based
deliveries - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
27c. No. of fetal deaths - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
27d. No. of abortion/
miscarriage - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0

Section C. Child Care a

Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
C1. Immunization Services
1. CPAB - Total 0 0 0 6. DPT-HiB-HepB 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
2. BCG - Total 0 0 0 7. OPV 1 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
3. HepB, within 24 hours. - Total 0 0 0 8. OPV 2 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
4. DPT-HiB-HepB 1 - Total 0 0 0 9. OPV 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
5. DPT-HiB-HepB 2 - Total 0 0 0 10. IPV - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
16. FIC - Total 0 0 0 18. Td, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
17. CIC - Total 0 0 0 19. MR, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
C2. Nutrition Services
22. Newborns initiated on breastfeeding
immediately after birth lasting to 90 mins - 28. Infants 6-11 mos. old seen - Total
Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
23. Preterm/LBW infants given iron 29. Infants 6-11 mos. given 1 dose of
supplementation - Total 0 0 0 Vitamin A 100,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
24. Infants 6 mos. old seen - Total 0 0 0 30. Children 12-59 mos seen - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
25. Infants exclusively breastfed until 6th month - 31. Children 12-59 mos. old given 2
Total 0 0 0 doses of Vitamin A 200,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
26. Infants 6 mos. old initiated to complementary 32. Infant 6-11 months old who completed
feeding with continued breastfeeding - Total 0 0 0 MNP supplementation - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
27. Infants 6 mos. old initiated to complementary
feeding but no longer or never been breastfed 33. Children 12-23 mos. seen - Total
- Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
0
40. 1-19 y/o given 2 doses of deworming drug - 42. SAC, 5-9 y/o dewormed (2 doses) -
Total 0 0 0 Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
41. PSAC, 1-4 y/o dewormed (2 doses) - Total 0 0 0
• NHTS 0
• Non-NHTS 0
0
44. Sick Infants 6-11 mos. old seen - Total 47. Sick Children 12-59 mos. old
0 0 0 received Vitamin A - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
45. Sick Infants 6-11 mos. old received 48. Diarrhea cases 0-59 months old seen
Vitamin A - Total 0 0 0 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
49. Diarrhea cases 0-59 months old
46. Sick Children 12-59 mos. old seen - Total
0 0 0 received ORS - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
 To be submitted Qua
Section E. Infectious Disease Preven
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
E1. Filariasis Prevention and Control E2. Schistosomiasis Prevention and Contro
1. No. of individual examined for lymphatic 1. No. of people 5-65 y/o who ingested
filariasis - Total 0 MDA drugs - Total
2. No. of individual examined found positive for 2. No. of patients seen - Total
lymphatic filariasis - Total 0 3. No. of suspected cases seen
3. No. of lymphatic filariasis cases examined with 4. No. acute clinically diagnosed cases -
manifestation of either lymphedema,hydrocele, Total
elephantiasis - Total
0 5. No. of confirmed acute cases - Total
6. No. of chronic clinically diagnosed
cases - Total
Section F. _________________________
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
 ___JANUARY_____ YEAR: ____2020___

M1
AGPAKO__________________________
_________________________
_________________________

BRGY
________________________
________________________
r submission to RHU/MHC

Services and Deworming for Women of Reproductive Age

Total A3. Deworming Services SES Total

Col. 3) (Col. 1) (Col. 2) (Col. 3)

NHTS Non-NHTS
1. No. of women 20-49 years old given 2 doses of
15 deworming drugs - Total
0 0 0
15
0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
on B. Maternal Care and Services
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

a. Number of pregnant women seen in the

first trimester who have normal BMI -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of pregnant women seen in the first
trimester who have low BMI - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

7. No. of pregnant women given iodine

capsules – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
8. No. of pregnant women given one dose
of deworming tablet - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
9. No. of pregnant women screened for
syphilis - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
10. No. of pregnant women tested positive
for syphilis - Total

0 0 0 0
 • NHTS 0
• Non-NHTS 0
11. No. of pregnant women screened for
Hepatitis B - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
18. No. of deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
19. No. of live births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20a. No. of live births with normal birth
weight - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20b. No. of live births with low birth weight
- Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
20c. No. of live births with unknown birth
weight- Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
21. No. of deliveries attended by skilled
health professionals - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col 3)  (Col. 4)
rks Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

24a. No. of deliveries in public health

facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
24b. No. of deliveries in private health
facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
25. No. of non-facility-based deliveries -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
26a. No. of vaginal deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
26b. No. of deliveries by cesarean
section – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
27a. No. of full-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
27b. No. of pre-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B3. Postpartum and Newborn Care
28. No. of postpartum women together
with their newborn who completed at
least 2 postpartum check-ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
 29. No. of postpartum women who
completed iron with folic acid
supplementation - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
30. No. of postpartum women with
Vitamin A supplementation – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
ction C. Child Care and Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)

epB 3 - Total 0 0 0 11. PCV 1 - Total 0 0

0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 12. PCV 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 13. PCV 3 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 14. MMR 1 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
0 0 0 15. MMR 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
1 (November) - Total 0 0 0 20. Td, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
e 1 (November) - Total 0 0 0 21. MR, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

34. Children 12-23 mos. who completed

1 mos. old seen - Total
MNP supplementation - Total
0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
 1 mos. given 1 dose of
35. Children 0-59 mos. seen - Total
100,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos seen - Total 0 0 0 36. Stunted - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos. old given 2
37. Wasted - Total
tamin A 200,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
1 months old who completed
38. Overweight/Obese - Total
lementation - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS

2-23 mos. seen - Total 39. Normal - Total

0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col. 1) (Col 2) (Col 3)

y/o dewormed (2 doses) - 43. Adolescents, 10-19 y/o dewormed

0 0 0 (2 doses) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

ren 12-59 mos. old 50. Diarrhea cases 0-59 mos. received
itamin A - Total 0 0 0 ORS w/ zinc - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old seen 51. Pneumonia cases 0-59 mos. old
0 0 0 seen - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old 52. Pneumonia cases 0-59 mos. old
ORS - Total 0 0 0 completed treatment - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
 To be submitted Quarterly
ous Disease Prevention and Control Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
miasis Prevention and Control E2. Schistosomiasis Prevention and Control (Con't.)
le 5-65 y/o who ingested 7. No. confirmed chronic cases - Total
- Total 0
nts seen - Total 0 8. No. of confirmed cases (acute and
ected cases seen 0 chronic) - Total
clinically diagnosed cases - 9. No. of cases treated - Total
0
rmed acute cases - Total 0 10. No. of confirmed chronic cases
nic clinically diagnosed referred to a hospital facility - Total
al 0
_________________________________________
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
M1
RGY
Total

(Col. 3)

New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
 0 0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0 0
0
0
0 0
0
0
0 0
0
0
 0 0
0
0

Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
 Total
(Col 4)

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Total
(Col 4)
0
0
0
0
0
0

0
0
0
 0
0
0
0
0
0

0
0
0

0
0
0

0
0
0
Total
(Col 4)

0
0
0

0
0
0

0
0
0

0
0
0
 Total
(Col 4)
't.)

Total
(Col 4)
 FHSIS REPORT for the MONTH: ___JANUARY_____
Name of Barangay: _____TAGPAKO_________
Name of BHS: _______________________
Name of Municipality/City: _______________________
Name of Province: ________________________
Projected Population of the Year: _______________________
For submission to RHU/MHC

Section A. Family Planning Services and Dewor

A1. Modern FP Unmet Need Age Total

(Col. 1) (Col. 2) (Col. 3)

10-14 15-19 20-49
1. No. of WRA with unmet
need for modern FP - Total 5 5 5
15
• NHTS 5 5 5 15
• Non-NHTS 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
a. Female Sterilization/ BTL - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
b. Male Sterilization/ NSV-Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
c. Condom - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d. Pills - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
 d.1 Pills-POP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d.2 Pills-COC - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
e. Injectables (DMPA/ POI) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
f. Implant - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g. IUD (IUD-I and IUD-PP) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.1 IUD-I- Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.2 IUD-PP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
h. NFP-LAM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
i. NFP-BBT - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
j. NFP-CMM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
k. NFP-STM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
l. NFP-SDM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
m. Total Current Users 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
Section B. Maternal Care
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
1. No. of pregnant women w/
at least 4 prenatal check-
ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
2. No. of pregnant women
assessed of their nutritional
status during the 1st tri. -Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
c. No. of pregnant women
seen in the first trimester
who have high BMI - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
3. No. of pregnant women for
the first time given 2 doses of
Td vaccination - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
4. No. of pregnant women for
the 2nd or more times given
at least 3 doses of Td
vaccination (Td2 Plus) - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
5. No. of pregnant women who
completed the dose of iron
with folic acid
supplementation - Total 0 0 0 0
 • NHTS 0
• Non-NHTS 0
6. No. of pregnant women who
completed doses of calcium
carbonate supplementation -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
12. No. of pregnant women
tested positive for Hepatitis
B - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
13. No. of pregnant women
screened for HIV - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
14. No. of pregnant women
tested for CBC or Hgb&Hct
count - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
15. No. of pregnant women
tested for CBC or Hgb&Hct
count diagnosed with
anemia - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
16. No. of pregnant women
screened for gestational
diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
17.   No. of pregnant women
tested positive for
gestational diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col 3)  (Col. 4)
 Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
a. No. of deliveries attended
by a doctor - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by a nurse – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
c. No. of deliveries attended
by midwives - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
22. No. of deliveries attended by
non-skilled health
professionals - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
a. No. of deliveries attended
by Hilot/TBA - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by others - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
23. No. of health facility-based
deliveries - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
27c. No. of fetal deaths - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
27d. No. of abortion/
miscarriage - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0

Section C. Child Care a

Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
C1. Immunization Services
1. CPAB - Total 0 0 0 6. DPT-HiB-HepB 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
2. BCG - Total 0 0 0 7. OPV 1 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
3. HepB, within 24 hours. - Total 0 0 0 8. OPV 2 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
4. DPT-HiB-HepB 1 - Total 0 0 0 9. OPV 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
5. DPT-HiB-HepB 2 - Total 0 0 0 10. IPV - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
16. FIC - Total 0 0 0 18. Td, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
17. CIC - Total 0 0 0 19. MR, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
C2. Nutrition Services
22. Newborns initiated on breastfeeding
immediately after birth lasting to 90 mins - 28. Infants 6-11 mos. old seen - Total
Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
23. Preterm/LBW infants given iron 29. Infants 6-11 mos. given 1 dose of
supplementation - Total 0 0 0 Vitamin A 100,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
24. Infants 6 mos. old seen - Total 0 0 0 30. Children 12-59 mos seen - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
25. Infants exclusively breastfed until 6th month - 31. Children 12-59 mos. old given 2
Total 0 0 0 doses of Vitamin A 200,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
26. Infants 6 mos. old initiated to complementary 32. Infant 6-11 months old who completed
feeding with continued breastfeeding - Total 0 0 0 MNP supplementation - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
27. Infants 6 mos. old initiated to complementary
feeding but no longer or never been breastfed 33. Children 12-23 mos. seen - Total
- Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
0
40. 1-19 y/o given 2 doses of deworming drug - 42. SAC, 5-9 y/o dewormed (2 doses) -
Total 0 0 0 Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
41. PSAC, 1-4 y/o dewormed (2 doses) - Total 0 0 0
• NHTS 0
• Non-NHTS 0
0
44. Sick Infants 6-11 mos. old seen - Total 47. Sick Children 12-59 mos. old
0 0 0 received Vitamin A - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
45. Sick Infants 6-11 mos. old received 48. Diarrhea cases 0-59 months old seen
Vitamin A - Total 0 0 0 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
49. Diarrhea cases 0-59 months old
46. Sick Children 12-59 mos. old seen - Total
0 0 0 received ORS - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
 To be submitted Qua
Section E. Infectious Disease Preven
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
E1. Filariasis Prevention and Control E2. Schistosomiasis Prevention and Contro
1. No. of individual examined for lymphatic 1. No. of people 5-65 y/o who ingested
filariasis - Total 0 MDA drugs - Total
2. No. of individual examined found positive for 2. No. of patients seen - Total
lymphatic filariasis - Total 0 3. No. of suspected cases seen
3. No. of lymphatic filariasis cases examined with 4. No. acute clinically diagnosed cases -
manifestation of either lymphedema,hydrocele, Total
elephantiasis - Total
0 5. No. of confirmed acute cases - Total
6. No. of chronic clinically diagnosed
cases - Total
Section F. _________________________
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
 ___JANUARY_____ YEAR: ____2020___

M1
AGPAKO__________________________
_________________________
_________________________

BRGY
________________________
________________________
r submission to RHU/MHC

Services and Deworming for Women of Reproductive Age

Total A3. Deworming Services SES Total

Col. 3) (Col. 1) (Col. 2) (Col. 3)

NHTS Non-NHTS
1. No. of women 20-49 years old given 2 doses of
15 deworming drugs - Total
0 0 0
15
0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
on B. Maternal Care and Services
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

a. Number of pregnant women seen in the

first trimester who have normal BMI -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of pregnant women seen in the first
trimester who have low BMI - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

7. No. of pregnant women given iodine

capsules – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
8. No. of pregnant women given one dose
of deworming tablet - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
9. No. of pregnant women screened for
syphilis - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
10. No. of pregnant women tested positive
for syphilis - Total

0 0 0 0
 • NHTS 0
• Non-NHTS 0
11. No. of pregnant women screened for
Hepatitis B - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
18. No. of deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
19. No. of live births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20a. No. of live births with normal birth
weight - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20b. No. of live births with low birth weight
- Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
20c. No. of live births with unknown birth
weight- Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
21. No. of deliveries attended by skilled
health professionals - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col 3)  (Col. 4)
rks Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

24a. No. of deliveries in public health

facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
24b. No. of deliveries in private health
facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
25. No. of non-facility-based deliveries -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
26a. No. of vaginal deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
26b. No. of deliveries by cesarean
section – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
27a. No. of full-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
27b. No. of pre-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B3. Postpartum and Newborn Care
28. No. of postpartum women together
with their newborn who completed at
least 2 postpartum check-ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
 29. No. of postpartum women who
completed iron with folic acid
supplementation - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
30. No. of postpartum women with
Vitamin A supplementation – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
ction C. Child Care and Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)

epB 3 - Total 0 0 0 11. PCV 1 - Total 0 0

0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 12. PCV 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 13. PCV 3 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 14. MMR 1 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
0 0 0 15. MMR 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
1 (November) - Total 0 0 0 20. Td, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
e 1 (November) - Total 0 0 0 21. MR, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

34. Children 12-23 mos. who completed

1 mos. old seen - Total
MNP supplementation - Total
0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
 1 mos. given 1 dose of
35. Children 0-59 mos. seen - Total
100,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos seen - Total 0 0 0 36. Stunted - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos. old given 2
37. Wasted - Total
tamin A 200,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
1 months old who completed
38. Overweight/Obese - Total
lementation - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS

2-23 mos. seen - Total 39. Normal - Total

0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col. 1) (Col 2) (Col 3)

y/o dewormed (2 doses) - 43. Adolescents, 10-19 y/o dewormed

0 0 0 (2 doses) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

ren 12-59 mos. old 50. Diarrhea cases 0-59 mos. received
itamin A - Total 0 0 0 ORS w/ zinc - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old seen 51. Pneumonia cases 0-59 mos. old
0 0 0 seen - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old 52. Pneumonia cases 0-59 mos. old
ORS - Total 0 0 0 completed treatment - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
 To be submitted Quarterly
ous Disease Prevention and Control Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
miasis Prevention and Control E2. Schistosomiasis Prevention and Control (Con't.)
le 5-65 y/o who ingested 7. No. confirmed chronic cases - Total
- Total 0
nts seen - Total 0 8. No. of confirmed cases (acute and
ected cases seen 0 chronic) - Total
clinically diagnosed cases - 9. No. of cases treated - Total
0
rmed acute cases - Total 0 10. No. of confirmed chronic cases
nic clinically diagnosed referred to a hospital facility - Total
al 0
_________________________________________
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
M1
RGY
Total

(Col. 3)

New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
 0 0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0 0
0
0
0 0
0
0
0 0
0
0
 0 0
0
0

Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
 Total
(Col 4)

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Total
(Col 4)
0
0
0
0
0
0

0
0
0
 0
0
0
0
0
0

0
0
0

0
0
0

0
0
0
Total
(Col 4)

0
0
0

0
0
0

0
0
0

0
0
0
 Total
(Col 4)
't.)

Total
(Col 4)
 FHSIS REPORT for the MONTH: ___JANUARY_____
Name of Barangay: _____TAGPAKO_________
Name of BHS: _______________________
Name of Municipality/City: _______________________
Name of Province: ________________________
Projected Population of the Year: _______________________
For submission to RHU/MHC

Section A. Family Planning Services and Dewor

A1. Modern FP Unmet Need Age Total

(Col. 1) (Col. 2) (Col. 3)

10-14 15-19 20-49
1. No. of WRA with unmet
need for modern FP - Total 5 5 5
15
• NHTS 5 5 5 15
• Non-NHTS 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
a. Female Sterilization/ BTL - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
b. Male Sterilization/ NSV-Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
c. Condom - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d. Pills - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
 d.1 Pills-POP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d.2 Pills-COC - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
e. Injectables (DMPA/ POI) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
f. Implant - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g. IUD (IUD-I and IUD-PP) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.1 IUD-I- Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.2 IUD-PP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
h. NFP-LAM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
i. NFP-BBT - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
j. NFP-CMM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
k. NFP-STM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
l. NFP-SDM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
m. Total Current Users 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
Section B. Maternal Care
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
1. No. of pregnant women w/
at least 4 prenatal check-
ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
2. No. of pregnant women
assessed of their nutritional
status during the 1st tri. -Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
c. No. of pregnant women
seen in the first trimester
who have high BMI - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
3. No. of pregnant women for
the first time given 2 doses of
Td vaccination - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
4. No. of pregnant women for
the 2nd or more times given
at least 3 doses of Td
vaccination (Td2 Plus) - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
5. No. of pregnant women who
completed the dose of iron
with folic acid
supplementation - Total 0 0 0 0
 • NHTS 0
• Non-NHTS 0
6. No. of pregnant women who
completed doses of calcium
carbonate supplementation -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
12. No. of pregnant women
tested positive for Hepatitis
B - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
13. No. of pregnant women
screened for HIV - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
14. No. of pregnant women
tested for CBC or Hgb&Hct
count - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
15. No. of pregnant women
tested for CBC or Hgb&Hct
count diagnosed with
anemia - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
16. No. of pregnant women
screened for gestational
diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
17.   No. of pregnant women
tested positive for
gestational diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col 3)  (Col. 4)
 Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
a. No. of deliveries attended
by a doctor - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by a nurse – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
c. No. of deliveries attended
by midwives - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
22. No. of deliveries attended by
non-skilled health
professionals - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
a. No. of deliveries attended
by Hilot/TBA - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by others - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
23. No. of health facility-based
deliveries - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
27c. No. of fetal deaths - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
27d. No. of abortion/
miscarriage - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0

Section C. Child Care a

Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
C1. Immunization Services
1. CPAB - Total 0 0 0 6. DPT-HiB-HepB 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
2. BCG - Total 0 0 0 7. OPV 1 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
3. HepB, within 24 hours. - Total 0 0 0 8. OPV 2 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
4. DPT-HiB-HepB 1 - Total 0 0 0 9. OPV 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
5. DPT-HiB-HepB 2 - Total 0 0 0 10. IPV - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
16. FIC - Total 0 0 0 18. Td, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
17. CIC - Total 0 0 0 19. MR, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
C2. Nutrition Services
22. Newborns initiated on breastfeeding
immediately after birth lasting to 90 mins - 28. Infants 6-11 mos. old seen - Total
Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
23. Preterm/LBW infants given iron 29. Infants 6-11 mos. given 1 dose of
supplementation - Total 0 0 0 Vitamin A 100,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
24. Infants 6 mos. old seen - Total 0 0 0 30. Children 12-59 mos seen - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
25. Infants exclusively breastfed until 6th month - 31. Children 12-59 mos. old given 2
Total 0 0 0 doses of Vitamin A 200,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
26. Infants 6 mos. old initiated to complementary 32. Infant 6-11 months old who completed
feeding with continued breastfeeding - Total 0 0 0 MNP supplementation - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
27. Infants 6 mos. old initiated to complementary
feeding but no longer or never been breastfed 33. Children 12-23 mos. seen - Total
- Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
0
40. 1-19 y/o given 2 doses of deworming drug - 42. SAC, 5-9 y/o dewormed (2 doses) -
Total 0 0 0 Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
41. PSAC, 1-4 y/o dewormed (2 doses) - Total 0 0 0
• NHTS 0
• Non-NHTS 0
0
44. Sick Infants 6-11 mos. old seen - Total 47. Sick Children 12-59 mos. old
0 0 0 received Vitamin A - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
45. Sick Infants 6-11 mos. old received 48. Diarrhea cases 0-59 months old seen
Vitamin A - Total 0 0 0 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
49. Diarrhea cases 0-59 months old
46. Sick Children 12-59 mos. old seen - Total
0 0 0 received ORS - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
 To be submitted Qua
Section E. Infectious Disease Preven
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
E1. Filariasis Prevention and Control E2. Schistosomiasis Prevention and Contro
1. No. of individual examined for lymphatic 1. No. of people 5-65 y/o who ingested
filariasis - Total 0 MDA drugs - Total
2. No. of individual examined found positive for 2. No. of patients seen - Total
lymphatic filariasis - Total 0 3. No. of suspected cases seen
3. No. of lymphatic filariasis cases examined with 4. No. acute clinically diagnosed cases -
manifestation of either lymphedema,hydrocele, Total
elephantiasis - Total
0 5. No. of confirmed acute cases - Total
6. No. of chronic clinically diagnosed
cases - Total
Section F. _________________________
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
 ___JANUARY_____ YEAR: ____2020___

M1
AGPAKO__________________________
_________________________
_________________________

BRGY
________________________
________________________
r submission to RHU/MHC

Services and Deworming for Women of Reproductive Age

Total A3. Deworming Services SES Total

Col. 3) (Col. 1) (Col. 2) (Col. 3)

NHTS Non-NHTS
1. No. of women 20-49 years old given 2 doses of
15 deworming drugs - Total
0 0 0
15
0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
on B. Maternal Care and Services
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

a. Number of pregnant women seen in the

first trimester who have normal BMI -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of pregnant women seen in the first
trimester who have low BMI - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

7. No. of pregnant women given iodine

capsules – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
8. No. of pregnant women given one dose
of deworming tablet - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
9. No. of pregnant women screened for
syphilis - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
10. No. of pregnant women tested positive
for syphilis - Total

0 0 0 0
 • NHTS 0
• Non-NHTS 0
11. No. of pregnant women screened for
Hepatitis B - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
18. No. of deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
19. No. of live births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20a. No. of live births with normal birth
weight - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20b. No. of live births with low birth weight
- Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
20c. No. of live births with unknown birth
weight- Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
21. No. of deliveries attended by skilled
health professionals - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col 3)  (Col. 4)
rks Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

24a. No. of deliveries in public health

facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
24b. No. of deliveries in private health
facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
25. No. of non-facility-based deliveries -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
26a. No. of vaginal deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
26b. No. of deliveries by cesarean
section – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
27a. No. of full-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
27b. No. of pre-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B3. Postpartum and Newborn Care
28. No. of postpartum women together
with their newborn who completed at
least 2 postpartum check-ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
 29. No. of postpartum women who
completed iron with folic acid
supplementation - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
30. No. of postpartum women with
Vitamin A supplementation – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
ction C. Child Care and Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)

epB 3 - Total 0 0 0 11. PCV 1 - Total 0 0

0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 12. PCV 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 13. PCV 3 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 14. MMR 1 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
0 0 0 15. MMR 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
1 (November) - Total 0 0 0 20. Td, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
e 1 (November) - Total 0 0 0 21. MR, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

34. Children 12-23 mos. who completed

1 mos. old seen - Total
MNP supplementation - Total
0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
 1 mos. given 1 dose of
35. Children 0-59 mos. seen - Total
100,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos seen - Total 0 0 0 36. Stunted - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos. old given 2
37. Wasted - Total
tamin A 200,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
1 months old who completed
38. Overweight/Obese - Total
lementation - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS

2-23 mos. seen - Total 39. Normal - Total

0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col. 1) (Col 2) (Col 3)

y/o dewormed (2 doses) - 43. Adolescents, 10-19 y/o dewormed

0 0 0 (2 doses) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

ren 12-59 mos. old 50. Diarrhea cases 0-59 mos. received
itamin A - Total 0 0 0 ORS w/ zinc - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old seen 51. Pneumonia cases 0-59 mos. old
0 0 0 seen - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old 52. Pneumonia cases 0-59 mos. old
ORS - Total 0 0 0 completed treatment - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
 To be submitted Quarterly
ous Disease Prevention and Control Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
miasis Prevention and Control E2. Schistosomiasis Prevention and Control (Con't.)
le 5-65 y/o who ingested 7. No. confirmed chronic cases - Total
- Total 0
nts seen - Total 0 8. No. of confirmed cases (acute and
ected cases seen 0 chronic) - Total
clinically diagnosed cases - 9. No. of cases treated - Total
0
rmed acute cases - Total 0 10. No. of confirmed chronic cases
nic clinically diagnosed referred to a hospital facility - Total
al 0
_________________________________________
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
M1
RGY
Total

(Col. 3)

New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
 0 0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0 0
0
0
0 0
0
0
0 0
0
0
 0 0
0
0

Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
 Total
(Col 4)

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Total
(Col 4)
0
0
0
0
0
0

0
0
0
 0
0
0
0
0
0

0
0
0

0
0
0

0
0
0
Total
(Col 4)

0
0
0

0
0
0

0
0
0

0
0
0
 Total
(Col 4)
't.)

Total
(Col 4)
 FHSIS REPORT for the MONTH: ___JANUARY_____
Name of Barangay: _____TAGPAKO_________
Name of BHS: _______________________
Name of Municipality/City: _______________________
Name of Province: ________________________
Projected Population of the Year: _______________________
For submission to RHU/MHC

Section A. Family Planning Services and Dewor

A1. Modern FP Unmet Need Age Total

(Col. 1) (Col. 2) (Col. 3)

10-14 15-19 20-49
1. No. of WRA with unmet
need for modern FP - Total 5 5 5
15
• NHTS 5 5 5 15
• Non-NHTS 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
a. Female Sterilization/ BTL - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
b. Male Sterilization/ NSV-Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
c. Condom - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d. Pills - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
 d.1 Pills-POP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d.2 Pills-COC - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
e. Injectables (DMPA/ POI) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
f. Implant - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g. IUD (IUD-I and IUD-PP) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.1 IUD-I- Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.2 IUD-PP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
h. NFP-LAM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
i. NFP-BBT - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
j. NFP-CMM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
k. NFP-STM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
l. NFP-SDM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
m. Total Current Users 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
Section B. Maternal Care
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
1. No. of pregnant women w/
at least 4 prenatal check-
ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
2. No. of pregnant women
assessed of their nutritional
status during the 1st tri. -Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
c. No. of pregnant women
seen in the first trimester
who have high BMI - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
3. No. of pregnant women for
the first time given 2 doses of
Td vaccination - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
4. No. of pregnant women for
the 2nd or more times given
at least 3 doses of Td
vaccination (Td2 Plus) - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
5. No. of pregnant women who
completed the dose of iron
with folic acid
supplementation - Total 0 0 0 0
 • NHTS 0
• Non-NHTS 0
6. No. of pregnant women who
completed doses of calcium
carbonate supplementation -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
12. No. of pregnant women
tested positive for Hepatitis
B - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
13. No. of pregnant women
screened for HIV - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
14. No. of pregnant women
tested for CBC or Hgb&Hct
count - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
15. No. of pregnant women
tested for CBC or Hgb&Hct
count diagnosed with
anemia - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
16. No. of pregnant women
screened for gestational
diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
17.   No. of pregnant women
tested positive for
gestational diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col 3)  (Col. 4)
 Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
a. No. of deliveries attended
by a doctor - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by a nurse – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
c. No. of deliveries attended
by midwives - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
22. No. of deliveries attended by
non-skilled health
professionals - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
a. No. of deliveries attended
by Hilot/TBA - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by others - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
23. No. of health facility-based
deliveries - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
27c. No. of fetal deaths - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
27d. No. of abortion/
miscarriage - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0

Section C. Child Care a

Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
C1. Immunization Services
1. CPAB - Total 0 0 0 6. DPT-HiB-HepB 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
2. BCG - Total 0 0 0 7. OPV 1 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
3. HepB, within 24 hours. - Total 0 0 0 8. OPV 2 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
4. DPT-HiB-HepB 1 - Total 0 0 0 9. OPV 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
5. DPT-HiB-HepB 2 - Total 0 0 0 10. IPV - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
16. FIC - Total 0 0 0 18. Td, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
17. CIC - Total 0 0 0 19. MR, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
C2. Nutrition Services
22. Newborns initiated on breastfeeding
immediately after birth lasting to 90 mins - 28. Infants 6-11 mos. old seen - Total
Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
23. Preterm/LBW infants given iron 29. Infants 6-11 mos. given 1 dose of
supplementation - Total 0 0 0 Vitamin A 100,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
24. Infants 6 mos. old seen - Total 0 0 0 30. Children 12-59 mos seen - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
25. Infants exclusively breastfed until 6th month - 31. Children 12-59 mos. old given 2
Total 0 0 0 doses of Vitamin A 200,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
26. Infants 6 mos. old initiated to complementary 32. Infant 6-11 months old who completed
feeding with continued breastfeeding - Total 0 0 0 MNP supplementation - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
27. Infants 6 mos. old initiated to complementary
feeding but no longer or never been breastfed 33. Children 12-23 mos. seen - Total
- Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
0
40. 1-19 y/o given 2 doses of deworming drug - 42. SAC, 5-9 y/o dewormed (2 doses) -
Total 0 0 0 Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
41. PSAC, 1-4 y/o dewormed (2 doses) - Total 0 0 0
• NHTS 0
• Non-NHTS 0
0
44. Sick Infants 6-11 mos. old seen - Total 47. Sick Children 12-59 mos. old
0 0 0 received Vitamin A - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
45. Sick Infants 6-11 mos. old received 48. Diarrhea cases 0-59 months old seen
Vitamin A - Total 0 0 0 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
49. Diarrhea cases 0-59 months old
46. Sick Children 12-59 mos. old seen - Total
0 0 0 received ORS - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
 To be submitted Qua
Section E. Infectious Disease Preven
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
E1. Filariasis Prevention and Control E2. Schistosomiasis Prevention and Contro
1. No. of individual examined for lymphatic 1. No. of people 5-65 y/o who ingested
filariasis - Total 0 MDA drugs - Total
2. No. of individual examined found positive for 2. No. of patients seen - Total
lymphatic filariasis - Total 0 3. No. of suspected cases seen
3. No. of lymphatic filariasis cases examined with 4. No. acute clinically diagnosed cases -
manifestation of either lymphedema,hydrocele, Total
elephantiasis - Total
0 5. No. of confirmed acute cases - Total
6. No. of chronic clinically diagnosed
cases - Total
Section F. _________________________
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
 ___JANUARY_____ YEAR: ____2020___

M1
AGPAKO__________________________
_________________________
_________________________

BRGY
________________________
________________________
r submission to RHU/MHC

Services and Deworming for Women of Reproductive Age

Total A3. Deworming Services SES Total

Col. 3) (Col. 1) (Col. 2) (Col. 3)

NHTS Non-NHTS
1. No. of women 20-49 years old given 2 doses of
15 deworming drugs - Total
0 0 0
15
0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
on B. Maternal Care and Services
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

a. Number of pregnant women seen in the

first trimester who have normal BMI -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of pregnant women seen in the first
trimester who have low BMI - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

7. No. of pregnant women given iodine

capsules – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
8. No. of pregnant women given one dose
of deworming tablet - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
9. No. of pregnant women screened for
syphilis - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
10. No. of pregnant women tested positive
for syphilis - Total

0 0 0 0
 • NHTS 0
• Non-NHTS 0
11. No. of pregnant women screened for
Hepatitis B - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
18. No. of deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
19. No. of live births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20a. No. of live births with normal birth
weight - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20b. No. of live births with low birth weight
- Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
20c. No. of live births with unknown birth
weight- Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
21. No. of deliveries attended by skilled
health professionals - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col 3)  (Col. 4)
rks Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

24a. No. of deliveries in public health

facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
24b. No. of deliveries in private health
facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
25. No. of non-facility-based deliveries -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
26a. No. of vaginal deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
26b. No. of deliveries by cesarean
section – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
27a. No. of full-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
27b. No. of pre-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B3. Postpartum and Newborn Care
28. No. of postpartum women together
with their newborn who completed at
least 2 postpartum check-ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
 29. No. of postpartum women who
completed iron with folic acid
supplementation - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
30. No. of postpartum women with
Vitamin A supplementation – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
ction C. Child Care and Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)

epB 3 - Total 0 0 0 11. PCV 1 - Total 0 0

0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 12. PCV 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 13. PCV 3 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 14. MMR 1 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
0 0 0 15. MMR 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
1 (November) - Total 0 0 0 20. Td, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
e 1 (November) - Total 0 0 0 21. MR, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

34. Children 12-23 mos. who completed

1 mos. old seen - Total
MNP supplementation - Total
0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
 1 mos. given 1 dose of
35. Children 0-59 mos. seen - Total
100,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos seen - Total 0 0 0 36. Stunted - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos. old given 2
37. Wasted - Total
tamin A 200,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
1 months old who completed
38. Overweight/Obese - Total
lementation - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS

2-23 mos. seen - Total 39. Normal - Total

0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col. 1) (Col 2) (Col 3)

y/o dewormed (2 doses) - 43. Adolescents, 10-19 y/o dewormed

0 0 0 (2 doses) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

ren 12-59 mos. old 50. Diarrhea cases 0-59 mos. received
itamin A - Total 0 0 0 ORS w/ zinc - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old seen 51. Pneumonia cases 0-59 mos. old
0 0 0 seen - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old 52. Pneumonia cases 0-59 mos. old
ORS - Total 0 0 0 completed treatment - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
 To be submitted Quarterly
ous Disease Prevention and Control Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
miasis Prevention and Control E2. Schistosomiasis Prevention and Control (Con't.)
le 5-65 y/o who ingested 7. No. confirmed chronic cases - Total
- Total 0
nts seen - Total 0 8. No. of confirmed cases (acute and
ected cases seen 0 chronic) - Total
clinically diagnosed cases - 9. No. of cases treated - Total
0
rmed acute cases - Total 0 10. No. of confirmed chronic cases
nic clinically diagnosed referred to a hospital facility - Total
al 0
_________________________________________
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
M1
RGY
Total

(Col. 3)

New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
 0 0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0 0
0
0
0 0
0
0
0 0
0
0
 0 0
0
0

Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
 Total
(Col 4)

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Total
(Col 4)
0
0
0
0
0
0

0
0
0
 0
0
0
0
0
0

0
0
0

0
0
0

0
0
0
Total
(Col 4)

0
0
0

0
0
0

0
0
0

0
0
0
 Total
(Col 4)
't.)

Total
(Col 4)
 FHSIS REPORT for the MONTH: ___JANUARY_____
Name of Barangay: _____TAGPAKO_________
Name of BHS: _______________________
Name of Municipality/City: _______________________
Name of Province: ________________________
Projected Population of the Year: _______________________
For submission to RHU/MHC

Section A. Family Planning Services and Dewor

A1. Modern FP Unmet Need Age Total

(Col. 1) (Col. 2) (Col. 3)

10-14 15-19 20-49
1. No. of WRA with unmet
need for modern FP - Total 5 5 5
15
• NHTS 5 5 5 15
• Non-NHTS 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
a. Female Sterilization/ BTL - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
b. Male Sterilization/ NSV-Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
c. Condom - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d. Pills - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
 d.1 Pills-POP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d.2 Pills-COC - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
e. Injectables (DMPA/ POI) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
f. Implant - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g. IUD (IUD-I and IUD-PP) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.1 IUD-I- Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.2 IUD-PP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
h. NFP-LAM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
i. NFP-BBT - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
j. NFP-CMM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
k. NFP-STM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
l. NFP-SDM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
m. Total Current Users 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
Section B. Maternal Care
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
1. No. of pregnant women w/
at least 4 prenatal check-
ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
2. No. of pregnant women
assessed of their nutritional
status during the 1st tri. -Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
c. No. of pregnant women
seen in the first trimester
who have high BMI - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
3. No. of pregnant women for
the first time given 2 doses of
Td vaccination - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
4. No. of pregnant women for
the 2nd or more times given
at least 3 doses of Td
vaccination (Td2 Plus) - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
5. No. of pregnant women who
completed the dose of iron
with folic acid
supplementation - Total 0 0 0 0
 • NHTS 0
• Non-NHTS 0
6. No. of pregnant women who
completed doses of calcium
carbonate supplementation -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
12. No. of pregnant women
tested positive for Hepatitis
B - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
13. No. of pregnant women
screened for HIV - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
14. No. of pregnant women
tested for CBC or Hgb&Hct
count - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
15. No. of pregnant women
tested for CBC or Hgb&Hct
count diagnosed with
anemia - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
16. No. of pregnant women
screened for gestational
diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
17.   No. of pregnant women
tested positive for
gestational diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col 3)  (Col. 4)
 Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
a. No. of deliveries attended
by a doctor - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by a nurse – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
c. No. of deliveries attended
by midwives - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
22. No. of deliveries attended by
non-skilled health
professionals - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
a. No. of deliveries attended
by Hilot/TBA - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by others - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
23. No. of health facility-based
deliveries - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
27c. No. of fetal deaths - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
27d. No. of abortion/
miscarriage - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0

Section C. Child Care a

Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
C1. Immunization Services
1. CPAB - Total 0 0 0 6. DPT-HiB-HepB 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
2. BCG - Total 0 0 0 7. OPV 1 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
3. HepB, within 24 hours. - Total 0 0 0 8. OPV 2 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
4. DPT-HiB-HepB 1 - Total 0 0 0 9. OPV 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
5. DPT-HiB-HepB 2 - Total 0 0 0 10. IPV - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
16. FIC - Total 0 0 0 18. Td, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
17. CIC - Total 0 0 0 19. MR, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
C2. Nutrition Services
22. Newborns initiated on breastfeeding
immediately after birth lasting to 90 mins - 28. Infants 6-11 mos. old seen - Total
Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
23. Preterm/LBW infants given iron 29. Infants 6-11 mos. given 1 dose of
supplementation - Total 0 0 0 Vitamin A 100,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
24. Infants 6 mos. old seen - Total 0 0 0 30. Children 12-59 mos seen - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
25. Infants exclusively breastfed until 6th month - 31. Children 12-59 mos. old given 2
Total 0 0 0 doses of Vitamin A 200,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
26. Infants 6 mos. old initiated to complementary 32. Infant 6-11 months old who completed
feeding with continued breastfeeding - Total 0 0 0 MNP supplementation - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
27. Infants 6 mos. old initiated to complementary
feeding but no longer or never been breastfed 33. Children 12-23 mos. seen - Total
- Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
0
40. 1-19 y/o given 2 doses of deworming drug - 42. SAC, 5-9 y/o dewormed (2 doses) -
Total 0 0 0 Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
41. PSAC, 1-4 y/o dewormed (2 doses) - Total 0 0 0
• NHTS 0
• Non-NHTS 0
0
44. Sick Infants 6-11 mos. old seen - Total 47. Sick Children 12-59 mos. old
0 0 0 received Vitamin A - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
45. Sick Infants 6-11 mos. old received 48. Diarrhea cases 0-59 months old seen
Vitamin A - Total 0 0 0 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
49. Diarrhea cases 0-59 months old
46. Sick Children 12-59 mos. old seen - Total
0 0 0 received ORS - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
 To be submitted Qua
Section E. Infectious Disease Preven
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
E1. Filariasis Prevention and Control E2. Schistosomiasis Prevention and Contro
1. No. of individual examined for lymphatic 1. No. of people 5-65 y/o who ingested
filariasis - Total 0 MDA drugs - Total
2. No. of individual examined found positive for 2. No. of patients seen - Total
lymphatic filariasis - Total 0 3. No. of suspected cases seen
3. No. of lymphatic filariasis cases examined with 4. No. acute clinically diagnosed cases -
manifestation of either lymphedema,hydrocele, Total
elephantiasis - Total
0 5. No. of confirmed acute cases - Total
6. No. of chronic clinically diagnosed
cases - Total
Section F. _________________________
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
 ___JANUARY_____ YEAR: ____2020___

M1
AGPAKO__________________________
_________________________
_________________________

BRGY
________________________
________________________
r submission to RHU/MHC

Services and Deworming for Women of Reproductive Age

Total A3. Deworming Services SES Total

Col. 3) (Col. 1) (Col. 2) (Col. 3)

NHTS Non-NHTS
1. No. of women 20-49 years old given 2 doses of
15 deworming drugs - Total
0 0 0
15
0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
on B. Maternal Care and Services
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

a. Number of pregnant women seen in the

first trimester who have normal BMI -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of pregnant women seen in the first
trimester who have low BMI - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

7. No. of pregnant women given iodine

capsules – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
8. No. of pregnant women given one dose
of deworming tablet - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
9. No. of pregnant women screened for
syphilis - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
10. No. of pregnant women tested positive
for syphilis - Total

0 0 0 0
 • NHTS 0
• Non-NHTS 0
11. No. of pregnant women screened for
Hepatitis B - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
18. No. of deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
19. No. of live births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20a. No. of live births with normal birth
weight - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20b. No. of live births with low birth weight
- Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
20c. No. of live births with unknown birth
weight- Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
21. No. of deliveries attended by skilled
health professionals - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col 3)  (Col. 4)
rks Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

24a. No. of deliveries in public health

facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
24b. No. of deliveries in private health
facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
25. No. of non-facility-based deliveries -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
26a. No. of vaginal deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
26b. No. of deliveries by cesarean
section – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
27a. No. of full-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
27b. No. of pre-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B3. Postpartum and Newborn Care
28. No. of postpartum women together
with their newborn who completed at
least 2 postpartum check-ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
 29. No. of postpartum women who
completed iron with folic acid
supplementation - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
30. No. of postpartum women with
Vitamin A supplementation – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
ction C. Child Care and Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)

epB 3 - Total 0 0 0 11. PCV 1 - Total 0 0

0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 12. PCV 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 13. PCV 3 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 14. MMR 1 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
0 0 0 15. MMR 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
1 (November) - Total 0 0 0 20. Td, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
e 1 (November) - Total 0 0 0 21. MR, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

34. Children 12-23 mos. who completed

1 mos. old seen - Total
MNP supplementation - Total
0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
 1 mos. given 1 dose of
35. Children 0-59 mos. seen - Total
100,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos seen - Total 0 0 0 36. Stunted - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos. old given 2
37. Wasted - Total
tamin A 200,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
1 months old who completed
38. Overweight/Obese - Total
lementation - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS

2-23 mos. seen - Total 39. Normal - Total

0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col. 1) (Col 2) (Col 3)

y/o dewormed (2 doses) - 43. Adolescents, 10-19 y/o dewormed

0 0 0 (2 doses) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

ren 12-59 mos. old 50. Diarrhea cases 0-59 mos. received
itamin A - Total 0 0 0 ORS w/ zinc - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old seen 51. Pneumonia cases 0-59 mos. old
0 0 0 seen - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old 52. Pneumonia cases 0-59 mos. old
ORS - Total 0 0 0 completed treatment - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
 To be submitted Quarterly
ous Disease Prevention and Control Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
miasis Prevention and Control E2. Schistosomiasis Prevention and Control (Con't.)
le 5-65 y/o who ingested 7. No. confirmed chronic cases - Total
- Total 0
nts seen - Total 0 8. No. of confirmed cases (acute and
ected cases seen 0 chronic) - Total
clinically diagnosed cases - 9. No. of cases treated - Total
0
rmed acute cases - Total 0 10. No. of confirmed chronic cases
nic clinically diagnosed referred to a hospital facility - Total
al 0
_________________________________________
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
M1
RGY
Total

(Col. 3)

New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
 0 0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0 0
0
0
0 0
0
0
0 0
0
0
 0 0
0
0

Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
 Total
(Col 4)

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Total
(Col 4)
0
0
0
0
0
0

0
0
0
 0
0
0
0
0
0

0
0
0

0
0
0

0
0
0
Total
(Col 4)

0
0
0

0
0
0

0
0
0

0
0
0
 Total
(Col 4)
't.)

Total
(Col 4)
 FHSIS REPORT for the MONTH: ___JANUARY_____
Name of Barangay: _____TAGPAKO_________
Name of BHS: _______________________
Name of Municipality/City: _______________________
Name of Province: ________________________
Projected Population of the Year: _______________________
For submission to RHU/MHC

Section A. Family Planning Services and Dewor

A1. Modern FP Unmet Need Age Total

(Col. 1) (Col. 2) (Col. 3)

10-14 15-19 20-49
1. No. of WRA with unmet
need for modern FP - Total 5 5 5
15
• NHTS 5 5 5 15
• Non-NHTS 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
a. Female Sterilization/ BTL - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
b. Male Sterilization/ NSV-Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
c. Condom - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d. Pills - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
 d.1 Pills-POP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d.2 Pills-COC - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
e. Injectables (DMPA/ POI) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
f. Implant - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g. IUD (IUD-I and IUD-PP) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.1 IUD-I- Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.2 IUD-PP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
h. NFP-LAM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
i. NFP-BBT - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
j. NFP-CMM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
k. NFP-STM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
l. NFP-SDM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
m. Total Current Users 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
Section B. Maternal Care
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
1. No. of pregnant women w/
at least 4 prenatal check-
ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
2. No. of pregnant women
assessed of their nutritional
status during the 1st tri. -Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
c. No. of pregnant women
seen in the first trimester
who have high BMI - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
3. No. of pregnant women for
the first time given 2 doses of
Td vaccination - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
4. No. of pregnant women for
the 2nd or more times given
at least 3 doses of Td
vaccination (Td2 Plus) - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
5. No. of pregnant women who
completed the dose of iron
with folic acid
supplementation - Total 0 0 0 0
 • NHTS 0
• Non-NHTS 0
6. No. of pregnant women who
completed doses of calcium
carbonate supplementation -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
12. No. of pregnant women
tested positive for Hepatitis
B - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
13. No. of pregnant women
screened for HIV - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
14. No. of pregnant women
tested for CBC or Hgb&Hct
count - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
15. No. of pregnant women
tested for CBC or Hgb&Hct
count diagnosed with
anemia - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
16. No. of pregnant women
screened for gestational
diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
17.   No. of pregnant women
tested positive for
gestational diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col 3)  (Col. 4)
 Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
a. No. of deliveries attended
by a doctor - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by a nurse – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
c. No. of deliveries attended
by midwives - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
22. No. of deliveries attended by
non-skilled health
professionals - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
a. No. of deliveries attended
by Hilot/TBA - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by others - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
23. No. of health facility-based
deliveries - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
27c. No. of fetal deaths - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
27d. No. of abortion/
miscarriage - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0

Section C. Child Care a

Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
C1. Immunization Services
1. CPAB - Total 0 0 0 6. DPT-HiB-HepB 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
2. BCG - Total 0 0 0 7. OPV 1 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
3. HepB, within 24 hours. - Total 0 0 0 8. OPV 2 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
4. DPT-HiB-HepB 1 - Total 0 0 0 9. OPV 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
5. DPT-HiB-HepB 2 - Total 0 0 0 10. IPV - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
16. FIC - Total 0 0 0 18. Td, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
17. CIC - Total 0 0 0 19. MR, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
C2. Nutrition Services
22. Newborns initiated on breastfeeding
immediately after birth lasting to 90 mins - 28. Infants 6-11 mos. old seen - Total
Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
23. Preterm/LBW infants given iron 29. Infants 6-11 mos. given 1 dose of
supplementation - Total 0 0 0 Vitamin A 100,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
24. Infants 6 mos. old seen - Total 0 0 0 30. Children 12-59 mos seen - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
25. Infants exclusively breastfed until 6th month - 31. Children 12-59 mos. old given 2
Total 0 0 0 doses of Vitamin A 200,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
26. Infants 6 mos. old initiated to complementary 32. Infant 6-11 months old who completed
feeding with continued breastfeeding - Total 0 0 0 MNP supplementation - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
27. Infants 6 mos. old initiated to complementary
feeding but no longer or never been breastfed 33. Children 12-23 mos. seen - Total
- Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
0
40. 1-19 y/o given 2 doses of deworming drug - 42. SAC, 5-9 y/o dewormed (2 doses) -
Total 0 0 0 Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
41. PSAC, 1-4 y/o dewormed (2 doses) - Total 0 0 0
• NHTS 0
• Non-NHTS 0
0
44. Sick Infants 6-11 mos. old seen - Total 47. Sick Children 12-59 mos. old
0 0 0 received Vitamin A - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
45. Sick Infants 6-11 mos. old received 48. Diarrhea cases 0-59 months old seen
Vitamin A - Total 0 0 0 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
49. Diarrhea cases 0-59 months old
46. Sick Children 12-59 mos. old seen - Total
0 0 0 received ORS - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
 To be submitted Qua
Section E. Infectious Disease Preven
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
E1. Filariasis Prevention and Control E2. Schistosomiasis Prevention and Contro
1. No. of individual examined for lymphatic 1. No. of people 5-65 y/o who ingested
filariasis - Total 0 MDA drugs - Total
2. No. of individual examined found positive for 2. No. of patients seen - Total
lymphatic filariasis - Total 0 3. No. of suspected cases seen
3. No. of lymphatic filariasis cases examined with 4. No. acute clinically diagnosed cases -
manifestation of either lymphedema,hydrocele, Total
elephantiasis - Total
0 5. No. of confirmed acute cases - Total
6. No. of chronic clinically diagnosed
cases - Total
Section F. _________________________
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
 ___JANUARY_____ YEAR: ____2020___

M1
AGPAKO__________________________
_________________________
_________________________

BRGY
________________________
________________________
r submission to RHU/MHC

Services and Deworming for Women of Reproductive Age

Total A3. Deworming Services SES Total

Col. 3) (Col. 1) (Col. 2) (Col. 3)

NHTS Non-NHTS
1. No. of women 20-49 years old given 2 doses of
15 deworming drugs - Total
0 0 0
15
0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
on B. Maternal Care and Services
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

a. Number of pregnant women seen in the

first trimester who have normal BMI -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of pregnant women seen in the first
trimester who have low BMI - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

7. No. of pregnant women given iodine

capsules – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
8. No. of pregnant women given one dose
of deworming tablet - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
9. No. of pregnant women screened for
syphilis - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
10. No. of pregnant women tested positive
for syphilis - Total

0 0 0 0
 • NHTS 0
• Non-NHTS 0
11. No. of pregnant women screened for
Hepatitis B - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
18. No. of deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
19. No. of live births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20a. No. of live births with normal birth
weight - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20b. No. of live births with low birth weight
- Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
20c. No. of live births with unknown birth
weight- Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
21. No. of deliveries attended by skilled
health professionals - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col 3)  (Col. 4)
rks Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

24a. No. of deliveries in public health

facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
24b. No. of deliveries in private health
facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
25. No. of non-facility-based deliveries -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
26a. No. of vaginal deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
26b. No. of deliveries by cesarean
section – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
27a. No. of full-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
27b. No. of pre-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B3. Postpartum and Newborn Care
28. No. of postpartum women together
with their newborn who completed at
least 2 postpartum check-ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
 29. No. of postpartum women who
completed iron with folic acid
supplementation - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
30. No. of postpartum women with
Vitamin A supplementation – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
ction C. Child Care and Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)

epB 3 - Total 0 0 0 11. PCV 1 - Total 0 0

0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 12. PCV 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 13. PCV 3 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 14. MMR 1 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
0 0 0 15. MMR 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
1 (November) - Total 0 0 0 20. Td, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
e 1 (November) - Total 0 0 0 21. MR, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

34. Children 12-23 mos. who completed

1 mos. old seen - Total
MNP supplementation - Total
0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
 1 mos. given 1 dose of
35. Children 0-59 mos. seen - Total
100,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos seen - Total 0 0 0 36. Stunted - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos. old given 2
37. Wasted - Total
tamin A 200,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
1 months old who completed
38. Overweight/Obese - Total
lementation - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS

2-23 mos. seen - Total 39. Normal - Total

0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col. 1) (Col 2) (Col 3)

y/o dewormed (2 doses) - 43. Adolescents, 10-19 y/o dewormed

0 0 0 (2 doses) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

ren 12-59 mos. old 50. Diarrhea cases 0-59 mos. received
itamin A - Total 0 0 0 ORS w/ zinc - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old seen 51. Pneumonia cases 0-59 mos. old
0 0 0 seen - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old 52. Pneumonia cases 0-59 mos. old
ORS - Total 0 0 0 completed treatment - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
 To be submitted Quarterly
ous Disease Prevention and Control Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
miasis Prevention and Control E2. Schistosomiasis Prevention and Control (Con't.)
le 5-65 y/o who ingested 7. No. confirmed chronic cases - Total
- Total 0
nts seen - Total 0 8. No. of confirmed cases (acute and
ected cases seen 0 chronic) - Total
clinically diagnosed cases - 9. No. of cases treated - Total
0
rmed acute cases - Total 0 10. No. of confirmed chronic cases
nic clinically diagnosed referred to a hospital facility - Total
al 0
_________________________________________
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
M1
RGY
Total

(Col. 3)

New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
 0 0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0 0
0
0
0 0
0
0
0 0
0
0
 0 0
0
0

Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
 Total
(Col 4)

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Total
(Col 4)
0
0
0
0
0
0

0
0
0
 0
0
0
0
0
0

0
0
0

0
0
0

0
0
0
Total
(Col 4)

0
0
0

0
0
0

0
0
0

0
0
0
 Total
(Col 4)
't.)

Total
(Col 4)
 FHSIS REPORT for the MONTH: ___JANUARY_____
Name of Barangay: _____TAGPAKO_________
Name of BHS: _______________________
Name of Municipality/City: _______________________
Name of Province: ________________________
Projected Population of the Year: _______________________
For submission to RHU/MHC

Section A. Family Planning Services and Dewor

A1. Modern FP Unmet Need Age Total

(Col. 1) (Col. 2) (Col. 3)

10-14 15-19 20-49
1. No. of WRA with unmet
need for modern FP - Total 5 5 5
15
• NHTS 5 5 5 15
• Non-NHTS 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
a. Female Sterilization/ BTL - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
b. Male Sterilization/ NSV-Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
c. Condom - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d. Pills - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
 d.1 Pills-POP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d.2 Pills-COC - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
e. Injectables (DMPA/ POI) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
f. Implant - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g. IUD (IUD-I and IUD-PP) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.1 IUD-I- Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.2 IUD-PP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
h. NFP-LAM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
i. NFP-BBT - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
j. NFP-CMM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
k. NFP-STM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
l. NFP-SDM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
m. Total Current Users 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
Section B. Maternal Care
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
1. No. of pregnant women w/
at least 4 prenatal check-
ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
2. No. of pregnant women
assessed of their nutritional
status during the 1st tri. -Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
c. No. of pregnant women
seen in the first trimester
who have high BMI - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
3. No. of pregnant women for
the first time given 2 doses of
Td vaccination - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
4. No. of pregnant women for
the 2nd or more times given
at least 3 doses of Td
vaccination (Td2 Plus) - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
5. No. of pregnant women who
completed the dose of iron
with folic acid
supplementation - Total 0 0 0 0
 • NHTS 0
• Non-NHTS 0
6. No. of pregnant women who
completed doses of calcium
carbonate supplementation -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
12. No. of pregnant women
tested positive for Hepatitis
B - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
13. No. of pregnant women
screened for HIV - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
14. No. of pregnant women
tested for CBC or Hgb&Hct
count - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
15. No. of pregnant women
tested for CBC or Hgb&Hct
count diagnosed with
anemia - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
16. No. of pregnant women
screened for gestational
diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
17.   No. of pregnant women
tested positive for
gestational diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col 3)  (Col. 4)
 Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
a. No. of deliveries attended
by a doctor - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by a nurse – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
c. No. of deliveries attended
by midwives - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
22. No. of deliveries attended by
non-skilled health
professionals - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
a. No. of deliveries attended
by Hilot/TBA - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by others - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
23. No. of health facility-based
deliveries - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
27c. No. of fetal deaths - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
27d. No. of abortion/
miscarriage - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0

Section C. Child Care a

Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
C1. Immunization Services
1. CPAB - Total 0 0 0 6. DPT-HiB-HepB 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
2. BCG - Total 0 0 0 7. OPV 1 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
3. HepB, within 24 hours. - Total 0 0 0 8. OPV 2 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
4. DPT-HiB-HepB 1 - Total 0 0 0 9. OPV 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
5. DPT-HiB-HepB 2 - Total 0 0 0 10. IPV - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
16. FIC - Total 0 0 0 18. Td, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
17. CIC - Total 0 0 0 19. MR, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
C2. Nutrition Services
22. Newborns initiated on breastfeeding
immediately after birth lasting to 90 mins - 28. Infants 6-11 mos. old seen - Total
Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
23. Preterm/LBW infants given iron 29. Infants 6-11 mos. given 1 dose of
supplementation - Total 0 0 0 Vitamin A 100,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
24. Infants 6 mos. old seen - Total 0 0 0 30. Children 12-59 mos seen - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
25. Infants exclusively breastfed until 6th month - 31. Children 12-59 mos. old given 2
Total 0 0 0 doses of Vitamin A 200,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
26. Infants 6 mos. old initiated to complementary 32. Infant 6-11 months old who completed
feeding with continued breastfeeding - Total 0 0 0 MNP supplementation - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
27. Infants 6 mos. old initiated to complementary
feeding but no longer or never been breastfed 33. Children 12-23 mos. seen - Total
- Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
0
40. 1-19 y/o given 2 doses of deworming drug - 42. SAC, 5-9 y/o dewormed (2 doses) -
Total 0 0 0 Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
41. PSAC, 1-4 y/o dewormed (2 doses) - Total 0 0 0
• NHTS 0
• Non-NHTS 0
0
44. Sick Infants 6-11 mos. old seen - Total 47. Sick Children 12-59 mos. old
0 0 0 received Vitamin A - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
45. Sick Infants 6-11 mos. old received 48. Diarrhea cases 0-59 months old seen
Vitamin A - Total 0 0 0 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
49. Diarrhea cases 0-59 months old
46. Sick Children 12-59 mos. old seen - Total
0 0 0 received ORS - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
 To be submitted Qua
Section E. Infectious Disease Preven
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
E1. Filariasis Prevention and Control E2. Schistosomiasis Prevention and Contro
1. No. of individual examined for lymphatic 1. No. of people 5-65 y/o who ingested
filariasis - Total 0 MDA drugs - Total
2. No. of individual examined found positive for 2. No. of patients seen - Total
lymphatic filariasis - Total 0 3. No. of suspected cases seen
3. No. of lymphatic filariasis cases examined with 4. No. acute clinically diagnosed cases -
manifestation of either lymphedema,hydrocele, Total
elephantiasis - Total
0 5. No. of confirmed acute cases - Total
6. No. of chronic clinically diagnosed
cases - Total
Section F. _________________________
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
 ___JANUARY_____ YEAR: ____2020___

M1
AGPAKO__________________________
_________________________
_________________________

BRGY
________________________
________________________
r submission to RHU/MHC

Services and Deworming for Women of Reproductive Age

Total A3. Deworming Services SES Total

Col. 3) (Col. 1) (Col. 2) (Col. 3)

NHTS Non-NHTS
1. No. of women 20-49 years old given 2 doses of
15 deworming drugs - Total
0 0 0
15
0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
on B. Maternal Care and Services
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

a. Number of pregnant women seen in the

first trimester who have normal BMI -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of pregnant women seen in the first
trimester who have low BMI - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

7. No. of pregnant women given iodine

capsules – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
8. No. of pregnant women given one dose
of deworming tablet - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
9. No. of pregnant women screened for
syphilis - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
10. No. of pregnant women tested positive
for syphilis - Total

0 0 0 0
 • NHTS 0
• Non-NHTS 0
11. No. of pregnant women screened for
Hepatitis B - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
18. No. of deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
19. No. of live births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20a. No. of live births with normal birth
weight - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20b. No. of live births with low birth weight
- Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
20c. No. of live births with unknown birth
weight- Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
21. No. of deliveries attended by skilled
health professionals - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col 3)  (Col. 4)
rks Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

24a. No. of deliveries in public health

facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
24b. No. of deliveries in private health
facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
25. No. of non-facility-based deliveries -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
26a. No. of vaginal deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
26b. No. of deliveries by cesarean
section – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
27a. No. of full-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
27b. No. of pre-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B3. Postpartum and Newborn Care
28. No. of postpartum women together
with their newborn who completed at
least 2 postpartum check-ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
 29. No. of postpartum women who
completed iron with folic acid
supplementation - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
30. No. of postpartum women with
Vitamin A supplementation – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
ction C. Child Care and Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)

epB 3 - Total 0 0 0 11. PCV 1 - Total 0 0

0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 12. PCV 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 13. PCV 3 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 14. MMR 1 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
0 0 0 15. MMR 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
1 (November) - Total 0 0 0 20. Td, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
e 1 (November) - Total 0 0 0 21. MR, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

34. Children 12-23 mos. who completed

1 mos. old seen - Total
MNP supplementation - Total
0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
 1 mos. given 1 dose of
35. Children 0-59 mos. seen - Total
100,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos seen - Total 0 0 0 36. Stunted - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos. old given 2
37. Wasted - Total
tamin A 200,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
1 months old who completed
38. Overweight/Obese - Total
lementation - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS

2-23 mos. seen - Total 39. Normal - Total

0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col. 1) (Col 2) (Col 3)

y/o dewormed (2 doses) - 43. Adolescents, 10-19 y/o dewormed

0 0 0 (2 doses) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

ren 12-59 mos. old 50. Diarrhea cases 0-59 mos. received
itamin A - Total 0 0 0 ORS w/ zinc - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old seen 51. Pneumonia cases 0-59 mos. old
0 0 0 seen - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old 52. Pneumonia cases 0-59 mos. old
ORS - Total 0 0 0 completed treatment - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
 To be submitted Quarterly
ous Disease Prevention and Control Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
miasis Prevention and Control E2. Schistosomiasis Prevention and Control (Con't.)
le 5-65 y/o who ingested 7. No. confirmed chronic cases - Total
- Total 0
nts seen - Total 0 8. No. of confirmed cases (acute and
ected cases seen 0 chronic) - Total
clinically diagnosed cases - 9. No. of cases treated - Total
0
rmed acute cases - Total 0 10. No. of confirmed chronic cases
nic clinically diagnosed referred to a hospital facility - Total
al 0
_________________________________________
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
M1
RGY
Total

(Col. 3)

New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
 0 0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0 0
0
0
0 0
0
0
0 0
0
0
 0 0
0
0

Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
 Total
(Col 4)

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Total
(Col 4)
0
0
0
0
0
0

0
0
0
 0
0
0
0
0
0

0
0
0

0
0
0

0
0
0
Total
(Col 4)

0
0
0

0
0
0

0
0
0

0
0
0
 Total
(Col 4)
't.)

Total
(Col 4)
 FHSIS REPORT for the MONTH: ___JANUARY_____
Name of Barangay: _____TAGPAKO_________
Name of BHS: _______________________
Name of Municipality/City: _______________________
Name of Province: ________________________
Projected Population of the Year: _______________________
For submission to RHU/MHC

Section A. Family Planning Services and Dewor

A1. Modern FP Unmet Need Age Total

(Col. 1) (Col. 2) (Col. 3)

10-14 15-19 20-49
1. No. of WRA with unmet
need for modern FP - Total 5 5 5
15
• NHTS 5 5 5 15
• Non-NHTS 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
a. Female Sterilization/ BTL - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
b. Male Sterilization/ NSV-Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
c. Condom - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d. Pills - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
 d.1 Pills-POP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d.2 Pills-COC - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
e. Injectables (DMPA/ POI) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
f. Implant - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g. IUD (IUD-I and IUD-PP) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.1 IUD-I- Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.2 IUD-PP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
h. NFP-LAM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
i. NFP-BBT - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
j. NFP-CMM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
k. NFP-STM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
l. NFP-SDM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
m. Total Current Users 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
Section B. Maternal Care
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
1. No. of pregnant women w/
at least 4 prenatal check-
ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
2. No. of pregnant women
assessed of their nutritional
status during the 1st tri. -Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
c. No. of pregnant women
seen in the first trimester
who have high BMI - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
3. No. of pregnant women for
the first time given 2 doses of
Td vaccination - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
4. No. of pregnant women for
the 2nd or more times given
at least 3 doses of Td
vaccination (Td2 Plus) - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
5. No. of pregnant women who
completed the dose of iron
with folic acid
supplementation - Total 0 0 0 0
 • NHTS 0
• Non-NHTS 0
6. No. of pregnant women who
completed doses of calcium
carbonate supplementation -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
12. No. of pregnant women
tested positive for Hepatitis
B - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
13. No. of pregnant women
screened for HIV - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
14. No. of pregnant women
tested for CBC or Hgb&Hct
count - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
15. No. of pregnant women
tested for CBC or Hgb&Hct
count diagnosed with
anemia - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
16. No. of pregnant women
screened for gestational
diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
17.   No. of pregnant women
tested positive for
gestational diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col 3)  (Col. 4)
 Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
a. No. of deliveries attended
by a doctor - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by a nurse – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
c. No. of deliveries attended
by midwives - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
22. No. of deliveries attended by
non-skilled health
professionals - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
a. No. of deliveries attended
by Hilot/TBA - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by others - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
23. No. of health facility-based
deliveries - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
27c. No. of fetal deaths - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
27d. No. of abortion/
miscarriage - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0

Section C. Child Care a

Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
C1. Immunization Services
1. CPAB - Total 0 0 0 6. DPT-HiB-HepB 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
2. BCG - Total 0 0 0 7. OPV 1 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
3. HepB, within 24 hours. - Total 0 0 0 8. OPV 2 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
4. DPT-HiB-HepB 1 - Total 0 0 0 9. OPV 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
5. DPT-HiB-HepB 2 - Total 0 0 0 10. IPV - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
16. FIC - Total 0 0 0 18. Td, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
17. CIC - Total 0 0 0 19. MR, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
C2. Nutrition Services
22. Newborns initiated on breastfeeding
immediately after birth lasting to 90 mins - 28. Infants 6-11 mos. old seen - Total
Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
23. Preterm/LBW infants given iron 29. Infants 6-11 mos. given 1 dose of
supplementation - Total 0 0 0 Vitamin A 100,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
24. Infants 6 mos. old seen - Total 0 0 0 30. Children 12-59 mos seen - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
25. Infants exclusively breastfed until 6th month - 31. Children 12-59 mos. old given 2
Total 0 0 0 doses of Vitamin A 200,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
26. Infants 6 mos. old initiated to complementary 32. Infant 6-11 months old who completed
feeding with continued breastfeeding - Total 0 0 0 MNP supplementation - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
27. Infants 6 mos. old initiated to complementary
feeding but no longer or never been breastfed 33. Children 12-23 mos. seen - Total
- Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
0
40. 1-19 y/o given 2 doses of deworming drug - 42. SAC, 5-9 y/o dewormed (2 doses) -
Total 0 0 0 Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
41. PSAC, 1-4 y/o dewormed (2 doses) - Total 0 0 0
• NHTS 0
• Non-NHTS 0
0
44. Sick Infants 6-11 mos. old seen - Total 47. Sick Children 12-59 mos. old
0 0 0 received Vitamin A - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
45. Sick Infants 6-11 mos. old received 48. Diarrhea cases 0-59 months old seen
Vitamin A - Total 0 0 0 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
49. Diarrhea cases 0-59 months old
46. Sick Children 12-59 mos. old seen - Total
0 0 0 received ORS - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
 To be submitted Qua
Section E. Infectious Disease Preven
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
E1. Filariasis Prevention and Control E2. Schistosomiasis Prevention and Contro
1. No. of individual examined for lymphatic 1. No. of people 5-65 y/o who ingested
filariasis - Total 0 MDA drugs - Total
2. No. of individual examined found positive for 2. No. of patients seen - Total
lymphatic filariasis - Total 0 3. No. of suspected cases seen
3. No. of lymphatic filariasis cases examined with 4. No. acute clinically diagnosed cases -
manifestation of either lymphedema,hydrocele, Total
elephantiasis - Total
0 5. No. of confirmed acute cases - Total
6. No. of chronic clinically diagnosed
cases - Total
Section F. _________________________
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
 ___JANUARY_____ YEAR: ____2020___

M1
AGPAKO__________________________
_________________________
_________________________

BRGY
________________________
________________________
r submission to RHU/MHC

Services and Deworming for Women of Reproductive Age

Total A3. Deworming Services SES Total

Col. 3) (Col. 1) (Col. 2) (Col. 3)

NHTS Non-NHTS
1. No. of women 20-49 years old given 2 doses of
15 deworming drugs - Total
0 0 0
15
0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
on B. Maternal Care and Services
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

a. Number of pregnant women seen in the

first trimester who have normal BMI -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of pregnant women seen in the first
trimester who have low BMI - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

7. No. of pregnant women given iodine

capsules – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
8. No. of pregnant women given one dose
of deworming tablet - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
9. No. of pregnant women screened for
syphilis - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
10. No. of pregnant women tested positive
for syphilis - Total

0 0 0 0
 • NHTS 0
• Non-NHTS 0
11. No. of pregnant women screened for
Hepatitis B - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
18. No. of deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
19. No. of live births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20a. No. of live births with normal birth
weight - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20b. No. of live births with low birth weight
- Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
20c. No. of live births with unknown birth
weight- Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
21. No. of deliveries attended by skilled
health professionals - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col 3)  (Col. 4)
rks Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

24a. No. of deliveries in public health

facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
24b. No. of deliveries in private health
facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
25. No. of non-facility-based deliveries -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
26a. No. of vaginal deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
26b. No. of deliveries by cesarean
section – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
27a. No. of full-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
27b. No. of pre-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B3. Postpartum and Newborn Care
28. No. of postpartum women together
with their newborn who completed at
least 2 postpartum check-ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
 29. No. of postpartum women who
completed iron with folic acid
supplementation - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
30. No. of postpartum women with
Vitamin A supplementation – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
ction C. Child Care and Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)

epB 3 - Total 0 0 0 11. PCV 1 - Total 0 0

0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 12. PCV 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 13. PCV 3 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 14. MMR 1 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
0 0 0 15. MMR 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
1 (November) - Total 0 0 0 20. Td, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
e 1 (November) - Total 0 0 0 21. MR, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

34. Children 12-23 mos. who completed

1 mos. old seen - Total
MNP supplementation - Total
0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
 1 mos. given 1 dose of
35. Children 0-59 mos. seen - Total
100,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos seen - Total 0 0 0 36. Stunted - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos. old given 2
37. Wasted - Total
tamin A 200,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
1 months old who completed
38. Overweight/Obese - Total
lementation - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS

2-23 mos. seen - Total 39. Normal - Total

0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col. 1) (Col 2) (Col 3)

y/o dewormed (2 doses) - 43. Adolescents, 10-19 y/o dewormed

0 0 0 (2 doses) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

ren 12-59 mos. old 50. Diarrhea cases 0-59 mos. received
itamin A - Total 0 0 0 ORS w/ zinc - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old seen 51. Pneumonia cases 0-59 mos. old
0 0 0 seen - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old 52. Pneumonia cases 0-59 mos. old
ORS - Total 0 0 0 completed treatment - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
 To be submitted Quarterly
ous Disease Prevention and Control Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
miasis Prevention and Control E2. Schistosomiasis Prevention and Control (Con't.)
le 5-65 y/o who ingested 7. No. confirmed chronic cases - Total
- Total 0
nts seen - Total 0 8. No. of confirmed cases (acute and
ected cases seen 0 chronic) - Total
clinically diagnosed cases - 9. No. of cases treated - Total
0
rmed acute cases - Total 0 10. No. of confirmed chronic cases
nic clinically diagnosed referred to a hospital facility - Total
al 0
_________________________________________
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
M1
RGY
Total

(Col. 3)

New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
 0 0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0 0
0
0
0 0
0
0
0 0
0
0
 0 0
0
0

Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
 Total
(Col 4)

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Total
(Col 4)
0
0
0
0
0
0

0
0
0
 0
0
0
0
0
0

0
0
0

0
0
0

0
0
0
Total
(Col 4)

0
0
0

0
0
0

0
0
0

0
0
0
 Total
(Col 4)
't.)

Total
(Col 4)
 FHSIS REPORT for the MONTH: ___JANUARY_____
Name of Barangay: _____TAGPAKO_________
Name of BHS: _______________________
Name of Municipality/City: _______________________
Name of Province: ________________________
Projected Population of the Year: _______________________
For submission to RHU/MHC

Section A. Family Planning Services and Dewor

A1. Modern FP Unmet Need Age Total

(Col. 1) (Col. 2) (Col. 3)

10-14 15-19 20-49
1. No. of WRA with unmet
need for modern FP - Total 5 5 5
15
• NHTS 5 5 5 15
• Non-NHTS 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
a. Female Sterilization/ BTL - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
b. Male Sterilization/ NSV-Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
c. Condom - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d. Pills - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
 d.1 Pills-POP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d.2 Pills-COC - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
e. Injectables (DMPA/ POI) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
f. Implant - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g. IUD (IUD-I and IUD-PP) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.1 IUD-I- Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.2 IUD-PP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
h. NFP-LAM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
i. NFP-BBT - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
j. NFP-CMM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
k. NFP-STM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
l. NFP-SDM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
m. Total Current Users 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
Section B. Maternal Care
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
1. No. of pregnant women w/
at least 4 prenatal check-
ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
2. No. of pregnant women
assessed of their nutritional
status during the 1st tri. -Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
c. No. of pregnant women
seen in the first trimester
who have high BMI - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
3. No. of pregnant women for
the first time given 2 doses of
Td vaccination - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
4. No. of pregnant women for
the 2nd or more times given
at least 3 doses of Td
vaccination (Td2 Plus) - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
5. No. of pregnant women who
completed the dose of iron
with folic acid
supplementation - Total 0 0 0 0
 • NHTS 0
• Non-NHTS 0
6. No. of pregnant women who
completed doses of calcium
carbonate supplementation -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
12. No. of pregnant women
tested positive for Hepatitis
B - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
13. No. of pregnant women
screened for HIV - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
14. No. of pregnant women
tested for CBC or Hgb&Hct
count - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
15. No. of pregnant women
tested for CBC or Hgb&Hct
count diagnosed with
anemia - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
16. No. of pregnant women
screened for gestational
diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
17.   No. of pregnant women
tested positive for
gestational diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col 3)  (Col. 4)
 Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
a. No. of deliveries attended
by a doctor - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by a nurse – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
c. No. of deliveries attended
by midwives - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
22. No. of deliveries attended by
non-skilled health
professionals - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
a. No. of deliveries attended
by Hilot/TBA - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by others - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
23. No. of health facility-based
deliveries - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
27c. No. of fetal deaths - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
27d. No. of abortion/
miscarriage - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0

Section C. Child Care a

Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
C1. Immunization Services
1. CPAB - Total 0 0 0 6. DPT-HiB-HepB 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
2. BCG - Total 0 0 0 7. OPV 1 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
3. HepB, within 24 hours. - Total 0 0 0 8. OPV 2 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
4. DPT-HiB-HepB 1 - Total 0 0 0 9. OPV 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
5. DPT-HiB-HepB 2 - Total 0 0 0 10. IPV - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
16. FIC - Total 0 0 0 18. Td, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
17. CIC - Total 0 0 0 19. MR, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
C2. Nutrition Services
22. Newborns initiated on breastfeeding
immediately after birth lasting to 90 mins - 28. Infants 6-11 mos. old seen - Total
Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
23. Preterm/LBW infants given iron 29. Infants 6-11 mos. given 1 dose of
supplementation - Total 0 0 0 Vitamin A 100,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
24. Infants 6 mos. old seen - Total 0 0 0 30. Children 12-59 mos seen - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
25. Infants exclusively breastfed until 6th month - 31. Children 12-59 mos. old given 2
Total 0 0 0 doses of Vitamin A 200,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
26. Infants 6 mos. old initiated to complementary 32. Infant 6-11 months old who completed
feeding with continued breastfeeding - Total 0 0 0 MNP supplementation - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
27. Infants 6 mos. old initiated to complementary
feeding but no longer or never been breastfed 33. Children 12-23 mos. seen - Total
- Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
0
40. 1-19 y/o given 2 doses of deworming drug - 42. SAC, 5-9 y/o dewormed (2 doses) -
Total 0 0 0 Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
41. PSAC, 1-4 y/o dewormed (2 doses) - Total 0 0 0
• NHTS 0
• Non-NHTS 0
0
44. Sick Infants 6-11 mos. old seen - Total 47. Sick Children 12-59 mos. old
0 0 0 received Vitamin A - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
45. Sick Infants 6-11 mos. old received 48. Diarrhea cases 0-59 months old seen
Vitamin A - Total 0 0 0 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
49. Diarrhea cases 0-59 months old
46. Sick Children 12-59 mos. old seen - Total
0 0 0 received ORS - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
 To be submitted Qua
Section E. Infectious Disease Preven
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
E1. Filariasis Prevention and Control E2. Schistosomiasis Prevention and Contro
1. No. of individual examined for lymphatic 1. No. of people 5-65 y/o who ingested
filariasis - Total 0 MDA drugs - Total
2. No. of individual examined found positive for 2. No. of patients seen - Total
lymphatic filariasis - Total 0 3. No. of suspected cases seen
3. No. of lymphatic filariasis cases examined with 4. No. acute clinically diagnosed cases -
manifestation of either lymphedema,hydrocele, Total
elephantiasis - Total
0 5. No. of confirmed acute cases - Total
6. No. of chronic clinically diagnosed
cases - Total
Section F. _________________________
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
 ___JANUARY_____ YEAR: ____2020___

M1
AGPAKO__________________________
_________________________
_________________________

BRGY
________________________
________________________
r submission to RHU/MHC

Services and Deworming for Women of Reproductive Age

Total A3. Deworming Services SES Total

Col. 3) (Col. 1) (Col. 2) (Col. 3)

NHTS Non-NHTS
1. No. of women 20-49 years old given 2 doses of
15 deworming drugs - Total
0 0 0
15
0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
on B. Maternal Care and Services
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

a. Number of pregnant women seen in the

first trimester who have normal BMI -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of pregnant women seen in the first
trimester who have low BMI - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

7. No. of pregnant women given iodine

capsules – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
8. No. of pregnant women given one dose
of deworming tablet - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
9. No. of pregnant women screened for
syphilis - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
10. No. of pregnant women tested positive
for syphilis - Total

0 0 0 0
 • NHTS 0
• Non-NHTS 0
11. No. of pregnant women screened for
Hepatitis B - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
18. No. of deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
19. No. of live births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20a. No. of live births with normal birth
weight - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20b. No. of live births with low birth weight
- Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
20c. No. of live births with unknown birth
weight- Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
21. No. of deliveries attended by skilled
health professionals - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col 3)  (Col. 4)
rks Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

24a. No. of deliveries in public health

facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
24b. No. of deliveries in private health
facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
25. No. of non-facility-based deliveries -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
26a. No. of vaginal deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
26b. No. of deliveries by cesarean
section – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
27a. No. of full-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
27b. No. of pre-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B3. Postpartum and Newborn Care
28. No. of postpartum women together
with their newborn who completed at
least 2 postpartum check-ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
 29. No. of postpartum women who
completed iron with folic acid
supplementation - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
30. No. of postpartum women with
Vitamin A supplementation – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
ction C. Child Care and Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)

epB 3 - Total 0 0 0 11. PCV 1 - Total 0 0

0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 12. PCV 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 13. PCV 3 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 14. MMR 1 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
0 0 0 15. MMR 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
1 (November) - Total 0 0 0 20. Td, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
e 1 (November) - Total 0 0 0 21. MR, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

34. Children 12-23 mos. who completed

1 mos. old seen - Total
MNP supplementation - Total
0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
 1 mos. given 1 dose of
35. Children 0-59 mos. seen - Total
100,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos seen - Total 0 0 0 36. Stunted - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos. old given 2
37. Wasted - Total
tamin A 200,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
1 months old who completed
38. Overweight/Obese - Total
lementation - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS

2-23 mos. seen - Total 39. Normal - Total

0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col. 1) (Col 2) (Col 3)

y/o dewormed (2 doses) - 43. Adolescents, 10-19 y/o dewormed

0 0 0 (2 doses) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

ren 12-59 mos. old 50. Diarrhea cases 0-59 mos. received
itamin A - Total 0 0 0 ORS w/ zinc - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old seen 51. Pneumonia cases 0-59 mos. old
0 0 0 seen - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old 52. Pneumonia cases 0-59 mos. old
ORS - Total 0 0 0 completed treatment - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
 To be submitted Quarterly
ous Disease Prevention and Control Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
miasis Prevention and Control E2. Schistosomiasis Prevention and Control (Con't.)
le 5-65 y/o who ingested 7. No. confirmed chronic cases - Total
- Total 0
nts seen - Total 0 8. No. of confirmed cases (acute and
ected cases seen 0 chronic) - Total
clinically diagnosed cases - 9. No. of cases treated - Total
0
rmed acute cases - Total 0 10. No. of confirmed chronic cases
nic clinically diagnosed referred to a hospital facility - Total
al 0
_________________________________________
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
M1
RGY
Total

(Col. 3)

New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
 0 0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0 0
0
0
0 0
0
0
0 0
0
0
 0 0
0
0

Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
 Total
(Col 4)

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Total
(Col 4)
0
0
0
0
0
0

0
0
0
 0
0
0
0
0
0

0
0
0

0
0
0

0
0
0
Total
(Col 4)

0
0
0

0
0
0

0
0
0

0
0
0
 Total
(Col 4)
't.)

Total
(Col 4)
 FHSIS REPORT for the MONTH: ___JANUARY_____
Name of Barangay: _____TAGPAKO_________
Name of BHS: _______________________
Name of Municipality/City: _______________________
Name of Province: ________________________
Projected Population of the Year: _______________________
For submission to RHU/MHC

Section A. Family Planning Services and Dewor

A1. Modern FP Unmet Need Age Total

(Col. 1) (Col. 2) (Col. 3)

10-14 15-19 20-49
1. No. of WRA with unmet
need for modern FP - Total 5 5 5
15
• NHTS 5 5 5 15
• Non-NHTS 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
a. Female Sterilization/ BTL - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
b. Male Sterilization/ NSV-Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
c. Condom - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d. Pills - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
 d.1 Pills-POP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d.2 Pills-COC - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
e. Injectables (DMPA/ POI) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
f. Implant - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g. IUD (IUD-I and IUD-PP) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.1 IUD-I- Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.2 IUD-PP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
h. NFP-LAM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
i. NFP-BBT - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
j. NFP-CMM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
k. NFP-STM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
l. NFP-SDM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
m. Total Current Users 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
Section B. Maternal Care
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
1. No. of pregnant women w/
at least 4 prenatal check-
ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
2. No. of pregnant women
assessed of their nutritional
status during the 1st tri. -Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
c. No. of pregnant women
seen in the first trimester
who have high BMI - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
3. No. of pregnant women for
the first time given 2 doses of
Td vaccination - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
4. No. of pregnant women for
the 2nd or more times given
at least 3 doses of Td
vaccination (Td2 Plus) - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
5. No. of pregnant women who
completed the dose of iron
with folic acid
supplementation - Total 0 0 0 0
 • NHTS 0
• Non-NHTS 0
6. No. of pregnant women who
completed doses of calcium
carbonate supplementation -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
12. No. of pregnant women
tested positive for Hepatitis
B - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
13. No. of pregnant women
screened for HIV - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
14. No. of pregnant women
tested for CBC or Hgb&Hct
count - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
15. No. of pregnant women
tested for CBC or Hgb&Hct
count diagnosed with
anemia - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
16. No. of pregnant women
screened for gestational
diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
17.   No. of pregnant women
tested positive for
gestational diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col 3)  (Col. 4)
 Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
a. No. of deliveries attended
by a doctor - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by a nurse – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
c. No. of deliveries attended
by midwives - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
22. No. of deliveries attended by
non-skilled health
professionals - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
a. No. of deliveries attended
by Hilot/TBA - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by others - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
23. No. of health facility-based
deliveries - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
27c. No. of fetal deaths - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
27d. No. of abortion/
miscarriage - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0

Section C. Child Care a

Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
C1. Immunization Services
1. CPAB - Total 0 0 0 6. DPT-HiB-HepB 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
2. BCG - Total 0 0 0 7. OPV 1 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
3. HepB, within 24 hours. - Total 0 0 0 8. OPV 2 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
4. DPT-HiB-HepB 1 - Total 0 0 0 9. OPV 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
5. DPT-HiB-HepB 2 - Total 0 0 0 10. IPV - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
16. FIC - Total 0 0 0 18. Td, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
17. CIC - Total 0 0 0 19. MR, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
C2. Nutrition Services
22. Newborns initiated on breastfeeding
immediately after birth lasting to 90 mins - 28. Infants 6-11 mos. old seen - Total
Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
23. Preterm/LBW infants given iron 29. Infants 6-11 mos. given 1 dose of
supplementation - Total 0 0 0 Vitamin A 100,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
24. Infants 6 mos. old seen - Total 0 0 0 30. Children 12-59 mos seen - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
25. Infants exclusively breastfed until 6th month - 31. Children 12-59 mos. old given 2
Total 0 0 0 doses of Vitamin A 200,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
26. Infants 6 mos. old initiated to complementary 32. Infant 6-11 months old who completed
feeding with continued breastfeeding - Total 0 0 0 MNP supplementation - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
27. Infants 6 mos. old initiated to complementary
feeding but no longer or never been breastfed 33. Children 12-23 mos. seen - Total
- Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
0
40. 1-19 y/o given 2 doses of deworming drug - 42. SAC, 5-9 y/o dewormed (2 doses) -
Total 0 0 0 Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
41. PSAC, 1-4 y/o dewormed (2 doses) - Total 0 0 0
• NHTS 0
• Non-NHTS 0
0
44. Sick Infants 6-11 mos. old seen - Total 47. Sick Children 12-59 mos. old
0 0 0 received Vitamin A - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
45. Sick Infants 6-11 mos. old received 48. Diarrhea cases 0-59 months old seen
Vitamin A - Total 0 0 0 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
49. Diarrhea cases 0-59 months old
46. Sick Children 12-59 mos. old seen - Total
0 0 0 received ORS - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
 To be submitted Qua
Section E. Infectious Disease Preven
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
E1. Filariasis Prevention and Control E2. Schistosomiasis Prevention and Contro
1. No. of individual examined for lymphatic 1. No. of people 5-65 y/o who ingested
filariasis - Total 0 MDA drugs - Total
2. No. of individual examined found positive for 2. No. of patients seen - Total
lymphatic filariasis - Total 0 3. No. of suspected cases seen
3. No. of lymphatic filariasis cases examined with 4. No. acute clinically diagnosed cases -
manifestation of either lymphedema,hydrocele, Total
elephantiasis - Total
0 5. No. of confirmed acute cases - Total
6. No. of chronic clinically diagnosed
cases - Total
Section F. _________________________
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
 ___JANUARY_____ YEAR: ____2020___

M1
AGPAKO__________________________
_________________________
_________________________

BRGY
________________________
________________________
r submission to RHU/MHC

Services and Deworming for Women of Reproductive Age

Total A3. Deworming Services SES Total

Col. 3) (Col. 1) (Col. 2) (Col. 3)

NHTS Non-NHTS
1. No. of women 20-49 years old given 2 doses of
15 deworming drugs - Total
0 0 0
15
0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
on B. Maternal Care and Services
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

a. Number of pregnant women seen in the

first trimester who have normal BMI -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of pregnant women seen in the first
trimester who have low BMI - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

7. No. of pregnant women given iodine

capsules – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
8. No. of pregnant women given one dose
of deworming tablet - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
9. No. of pregnant women screened for
syphilis - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
10. No. of pregnant women tested positive
for syphilis - Total

0 0 0 0
 • NHTS 0
• Non-NHTS 0
11. No. of pregnant women screened for
Hepatitis B - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
18. No. of deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
19. No. of live births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20a. No. of live births with normal birth
weight - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20b. No. of live births with low birth weight
- Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
20c. No. of live births with unknown birth
weight- Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
21. No. of deliveries attended by skilled
health professionals - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col 3)  (Col. 4)
rks Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

24a. No. of deliveries in public health

facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
24b. No. of deliveries in private health
facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
25. No. of non-facility-based deliveries -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
26a. No. of vaginal deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
26b. No. of deliveries by cesarean
section – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
27a. No. of full-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
27b. No. of pre-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B3. Postpartum and Newborn Care
28. No. of postpartum women together
with their newborn who completed at
least 2 postpartum check-ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
 29. No. of postpartum women who
completed iron with folic acid
supplementation - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
30. No. of postpartum women with
Vitamin A supplementation – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
ction C. Child Care and Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)

epB 3 - Total 0 0 0 11. PCV 1 - Total 0 0

0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 12. PCV 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 13. PCV 3 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 14. MMR 1 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
0 0 0 15. MMR 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
1 (November) - Total 0 0 0 20. Td, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
e 1 (November) - Total 0 0 0 21. MR, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

34. Children 12-23 mos. who completed

1 mos. old seen - Total
MNP supplementation - Total
0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
 1 mos. given 1 dose of
35. Children 0-59 mos. seen - Total
100,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos seen - Total 0 0 0 36. Stunted - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos. old given 2
37. Wasted - Total
tamin A 200,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
1 months old who completed
38. Overweight/Obese - Total
lementation - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS

2-23 mos. seen - Total 39. Normal - Total

0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col. 1) (Col 2) (Col 3)

y/o dewormed (2 doses) - 43. Adolescents, 10-19 y/o dewormed

0 0 0 (2 doses) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

ren 12-59 mos. old 50. Diarrhea cases 0-59 mos. received
itamin A - Total 0 0 0 ORS w/ zinc - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old seen 51. Pneumonia cases 0-59 mos. old
0 0 0 seen - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old 52. Pneumonia cases 0-59 mos. old
ORS - Total 0 0 0 completed treatment - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
 To be submitted Quarterly
ous Disease Prevention and Control Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
miasis Prevention and Control E2. Schistosomiasis Prevention and Control (Con't.)
le 5-65 y/o who ingested 7. No. confirmed chronic cases - Total
- Total 0
nts seen - Total 0 8. No. of confirmed cases (acute and
ected cases seen 0 chronic) - Total
clinically diagnosed cases - 9. No. of cases treated - Total
0
rmed acute cases - Total 0 10. No. of confirmed chronic cases
nic clinically diagnosed referred to a hospital facility - Total
al 0
_________________________________________
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
M1
RGY
Total

(Col. 3)

New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
 0 0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0 0
0
0
0 0
0
0
0 0
0
0
 0 0
0
0

Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
 Total
(Col 4)

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Total
(Col 4)
0
0
0
0
0
0

0
0
0
 0
0
0
0
0
0

0
0
0

0
0
0

0
0
0
Total
(Col 4)

0
0
0

0
0
0

0
0
0

0
0
0
 Total
(Col 4)
't.)

Total
(Col 4)
 FHSIS REPORT for the MONTH: ___JANUARY_____
Name of Barangay: _____TAGPAKO_________
Name of BHS: _______________________
Name of Municipality/City: _______________________
Name of Province: ________________________
Projected Population of the Year: _______________________
For submission to RHU/MHC

Section A. Family Planning Services and Dewor

A1. Modern FP Unmet Need Age Total

(Col. 1) (Col. 2) (Col. 3)

10-14 15-19 20-49
1. No. of WRA with unmet
need for modern FP - Total 5 5 5
15
• NHTS 5 5 5 15
• Non-NHTS 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
a. Female Sterilization/ BTL - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
b. Male Sterilization/ NSV-Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
c. Condom - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d. Pills - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
 d.1 Pills-POP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d.2 Pills-COC - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
e. Injectables (DMPA/ POI) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
f. Implant - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g. IUD (IUD-I and IUD-PP) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.1 IUD-I- Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.2 IUD-PP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
h. NFP-LAM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
i. NFP-BBT - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
j. NFP-CMM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
k. NFP-STM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
l. NFP-SDM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
m. Total Current Users 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
Section B. Maternal Care
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
1. No. of pregnant women w/
at least 4 prenatal check-
ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
2. No. of pregnant women
assessed of their nutritional
status during the 1st tri. -Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
c. No. of pregnant women
seen in the first trimester
who have high BMI - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
3. No. of pregnant women for
the first time given 2 doses of
Td vaccination - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
4. No. of pregnant women for
the 2nd or more times given
at least 3 doses of Td
vaccination (Td2 Plus) - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
5. No. of pregnant women who
completed the dose of iron
with folic acid
supplementation - Total 0 0 0 0
 • NHTS 0
• Non-NHTS 0
6. No. of pregnant women who
completed doses of calcium
carbonate supplementation -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
12. No. of pregnant women
tested positive for Hepatitis
B - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
13. No. of pregnant women
screened for HIV - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
14. No. of pregnant women
tested for CBC or Hgb&Hct
count - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
15. No. of pregnant women
tested for CBC or Hgb&Hct
count diagnosed with
anemia - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
16. No. of pregnant women
screened for gestational
diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
17.   No. of pregnant women
tested positive for
gestational diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col 3)  (Col. 4)
 Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
a. No. of deliveries attended
by a doctor - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by a nurse – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
c. No. of deliveries attended
by midwives - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
22. No. of deliveries attended by
non-skilled health
professionals - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
a. No. of deliveries attended
by Hilot/TBA - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by others - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
23. No. of health facility-based
deliveries - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
27c. No. of fetal deaths - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
27d. No. of abortion/
miscarriage - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0

Section C. Child Care a

Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
C1. Immunization Services
1. CPAB - Total 0 0 0 6. DPT-HiB-HepB 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
2. BCG - Total 0 0 0 7. OPV 1 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
3. HepB, within 24 hours. - Total 0 0 0 8. OPV 2 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
4. DPT-HiB-HepB 1 - Total 0 0 0 9. OPV 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
5. DPT-HiB-HepB 2 - Total 0 0 0 10. IPV - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
16. FIC - Total 0 0 0 18. Td, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
17. CIC - Total 0 0 0 19. MR, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
C2. Nutrition Services
22. Newborns initiated on breastfeeding
immediately after birth lasting to 90 mins - 28. Infants 6-11 mos. old seen - Total
Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
23. Preterm/LBW infants given iron 29. Infants 6-11 mos. given 1 dose of
supplementation - Total 0 0 0 Vitamin A 100,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
24. Infants 6 mos. old seen - Total 0 0 0 30. Children 12-59 mos seen - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
25. Infants exclusively breastfed until 6th month - 31. Children 12-59 mos. old given 2
Total 0 0 0 doses of Vitamin A 200,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
26. Infants 6 mos. old initiated to complementary 32. Infant 6-11 months old who completed
feeding with continued breastfeeding - Total 0 0 0 MNP supplementation - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
27. Infants 6 mos. old initiated to complementary
feeding but no longer or never been breastfed 33. Children 12-23 mos. seen - Total
- Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
0
40. 1-19 y/o given 2 doses of deworming drug - 42. SAC, 5-9 y/o dewormed (2 doses) -
Total 0 0 0 Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
41. PSAC, 1-4 y/o dewormed (2 doses) - Total 0 0 0
• NHTS 0
• Non-NHTS 0
0
44. Sick Infants 6-11 mos. old seen - Total 47. Sick Children 12-59 mos. old
0 0 0 received Vitamin A - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
45. Sick Infants 6-11 mos. old received 48. Diarrhea cases 0-59 months old seen
Vitamin A - Total 0 0 0 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
49. Diarrhea cases 0-59 months old
46. Sick Children 12-59 mos. old seen - Total
0 0 0 received ORS - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
 To be submitted Qua
Section E. Infectious Disease Preven
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
E1. Filariasis Prevention and Control E2. Schistosomiasis Prevention and Contro
1. No. of individual examined for lymphatic 1. No. of people 5-65 y/o who ingested
filariasis - Total 0 MDA drugs - Total
2. No. of individual examined found positive for 2. No. of patients seen - Total
lymphatic filariasis - Total 0 3. No. of suspected cases seen
3. No. of lymphatic filariasis cases examined with 4. No. acute clinically diagnosed cases -
manifestation of either lymphedema,hydrocele, Total
elephantiasis - Total
0 5. No. of confirmed acute cases - Total
6. No. of chronic clinically diagnosed
cases - Total
Section F. _________________________
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
 ___JANUARY_____ YEAR: ____2020___

M1
AGPAKO__________________________
_________________________
_________________________

BRGY
________________________
________________________
r submission to RHU/MHC

Services and Deworming for Women of Reproductive Age

Total A3. Deworming Services SES Total

Col. 3) (Col. 1) (Col. 2) (Col. 3)

NHTS Non-NHTS
1. No. of women 20-49 years old given 2 doses of
15 deworming drugs - Total
0 0 0
15
0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
on B. Maternal Care and Services
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

a. Number of pregnant women seen in the

first trimester who have normal BMI -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of pregnant women seen in the first
trimester who have low BMI - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

7. No. of pregnant women given iodine

capsules – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
8. No. of pregnant women given one dose
of deworming tablet - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
9. No. of pregnant women screened for
syphilis - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
10. No. of pregnant women tested positive
for syphilis - Total

0 0 0 0
 • NHTS 0
• Non-NHTS 0
11. No. of pregnant women screened for
Hepatitis B - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
18. No. of deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
19. No. of live births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20a. No. of live births with normal birth
weight - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20b. No. of live births with low birth weight
- Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
20c. No. of live births with unknown birth
weight- Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
21. No. of deliveries attended by skilled
health professionals - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col 3)  (Col. 4)
rks Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

24a. No. of deliveries in public health

facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
24b. No. of deliveries in private health
facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
25. No. of non-facility-based deliveries -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
26a. No. of vaginal deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
26b. No. of deliveries by cesarean
section – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
27a. No. of full-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
27b. No. of pre-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B3. Postpartum and Newborn Care
28. No. of postpartum women together
with their newborn who completed at
least 2 postpartum check-ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
 29. No. of postpartum women who
completed iron with folic acid
supplementation - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
30. No. of postpartum women with
Vitamin A supplementation – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
ction C. Child Care and Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)

epB 3 - Total 0 0 0 11. PCV 1 - Total 0 0

0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 12. PCV 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 13. PCV 3 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 14. MMR 1 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
0 0 0 15. MMR 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
1 (November) - Total 0 0 0 20. Td, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
e 1 (November) - Total 0 0 0 21. MR, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

34. Children 12-23 mos. who completed

1 mos. old seen - Total
MNP supplementation - Total
0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
 1 mos. given 1 dose of
35. Children 0-59 mos. seen - Total
100,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos seen - Total 0 0 0 36. Stunted - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos. old given 2
37. Wasted - Total
tamin A 200,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
1 months old who completed
38. Overweight/Obese - Total
lementation - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS

2-23 mos. seen - Total 39. Normal - Total

0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col. 1) (Col 2) (Col 3)

y/o dewormed (2 doses) - 43. Adolescents, 10-19 y/o dewormed

0 0 0 (2 doses) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

ren 12-59 mos. old 50. Diarrhea cases 0-59 mos. received
itamin A - Total 0 0 0 ORS w/ zinc - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old seen 51. Pneumonia cases 0-59 mos. old
0 0 0 seen - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old 52. Pneumonia cases 0-59 mos. old
ORS - Total 0 0 0 completed treatment - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
 To be submitted Quarterly
ous Disease Prevention and Control Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
miasis Prevention and Control E2. Schistosomiasis Prevention and Control (Con't.)
le 5-65 y/o who ingested 7. No. confirmed chronic cases - Total
- Total 0
nts seen - Total 0 8. No. of confirmed cases (acute and
ected cases seen 0 chronic) - Total
clinically diagnosed cases - 9. No. of cases treated - Total
0
rmed acute cases - Total 0 10. No. of confirmed chronic cases
nic clinically diagnosed referred to a hospital facility - Total
al 0
_________________________________________
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
M1
RGY
Total

(Col. 3)

New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
 0 0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0 0
0
0
0 0
0
0
0 0
0
0
 0 0
0
0

Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
 Total
(Col 4)

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Total
(Col 4)
0
0
0
0
0
0

0
0
0
 0
0
0
0
0
0

0
0
0

0
0
0

0
0
0
Total
(Col 4)

0
0
0

0
0
0

0
0
0

0
0
0
 Total
(Col 4)
't.)

Total
(Col 4)
 FHSIS REPORT for the MONTH: ___JANUARY_____
Name of Barangay: _____TAGPAKO_________
Name of BHS: _______________________
Name of Municipality/City: _______________________
Name of Province: ________________________
Projected Population of the Year: _______________________
For submission to RHU/MHC

Section A. Family Planning Services and Dewor

A1. Modern FP Unmet Need Age Total

(Col. 1) (Col. 2) (Col. 3)

10-14 15-19 20-49
1. No. of WRA with unmet
need for modern FP - Total 5 5 5
15
• NHTS 5 5 5 15
• Non-NHTS 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
a. Female Sterilization/ BTL - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
b. Male Sterilization/ NSV-Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
c. Condom - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d. Pills - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
 d.1 Pills-POP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d.2 Pills-COC - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
e. Injectables (DMPA/ POI) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
f. Implant - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g. IUD (IUD-I and IUD-PP) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.1 IUD-I- Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.2 IUD-PP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
h. NFP-LAM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
i. NFP-BBT - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
j. NFP-CMM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
k. NFP-STM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
l. NFP-SDM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
m. Total Current Users 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
Section B. Maternal Care
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
1. No. of pregnant women w/
at least 4 prenatal check-
ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
2. No. of pregnant women
assessed of their nutritional
status during the 1st tri. -Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
c. No. of pregnant women
seen in the first trimester
who have high BMI - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
3. No. of pregnant women for
the first time given 2 doses of
Td vaccination - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
4. No. of pregnant women for
the 2nd or more times given
at least 3 doses of Td
vaccination (Td2 Plus) - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
5. No. of pregnant women who
completed the dose of iron
with folic acid
supplementation - Total 0 0 0 0
 • NHTS 0
• Non-NHTS 0
6. No. of pregnant women who
completed doses of calcium
carbonate supplementation -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
12. No. of pregnant women
tested positive for Hepatitis
B - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
13. No. of pregnant women
screened for HIV - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
14. No. of pregnant women
tested for CBC or Hgb&Hct
count - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
15. No. of pregnant women
tested for CBC or Hgb&Hct
count diagnosed with
anemia - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
16. No. of pregnant women
screened for gestational
diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
17.   No. of pregnant women
tested positive for
gestational diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col 3)  (Col. 4)
 Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
a. No. of deliveries attended
by a doctor - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by a nurse – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
c. No. of deliveries attended
by midwives - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
22. No. of deliveries attended by
non-skilled health
professionals - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
a. No. of deliveries attended
by Hilot/TBA - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by others - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
23. No. of health facility-based
deliveries - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
27c. No. of fetal deaths - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
27d. No. of abortion/
miscarriage - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0

Section C. Child Care a

Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
C1. Immunization Services
1. CPAB - Total 0 0 0 6. DPT-HiB-HepB 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
2. BCG - Total 0 0 0 7. OPV 1 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
3. HepB, within 24 hours. - Total 0 0 0 8. OPV 2 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
4. DPT-HiB-HepB 1 - Total 0 0 0 9. OPV 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
5. DPT-HiB-HepB 2 - Total 0 0 0 10. IPV - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
16. FIC - Total 0 0 0 18. Td, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
17. CIC - Total 0 0 0 19. MR, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
C2. Nutrition Services
22. Newborns initiated on breastfeeding
immediately after birth lasting to 90 mins - 28. Infants 6-11 mos. old seen - Total
Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
23. Preterm/LBW infants given iron 29. Infants 6-11 mos. given 1 dose of
supplementation - Total 0 0 0 Vitamin A 100,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
24. Infants 6 mos. old seen - Total 0 0 0 30. Children 12-59 mos seen - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
25. Infants exclusively breastfed until 6th month - 31. Children 12-59 mos. old given 2
Total 0 0 0 doses of Vitamin A 200,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
26. Infants 6 mos. old initiated to complementary 32. Infant 6-11 months old who completed
feeding with continued breastfeeding - Total 0 0 0 MNP supplementation - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
27. Infants 6 mos. old initiated to complementary
feeding but no longer or never been breastfed 33. Children 12-23 mos. seen - Total
- Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
0
40. 1-19 y/o given 2 doses of deworming drug - 42. SAC, 5-9 y/o dewormed (2 doses) -
Total 0 0 0 Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
41. PSAC, 1-4 y/o dewormed (2 doses) - Total 0 0 0
• NHTS 0
• Non-NHTS 0
0
44. Sick Infants 6-11 mos. old seen - Total 47. Sick Children 12-59 mos. old
0 0 0 received Vitamin A - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
45. Sick Infants 6-11 mos. old received 48. Diarrhea cases 0-59 months old seen
Vitamin A - Total 0 0 0 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
49. Diarrhea cases 0-59 months old
46. Sick Children 12-59 mos. old seen - Total
0 0 0 received ORS - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
 To be submitted Qua
Section E. Infectious Disease Preven
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
E1. Filariasis Prevention and Control E2. Schistosomiasis Prevention and Contro
1. No. of individual examined for lymphatic 1. No. of people 5-65 y/o who ingested
filariasis - Total 0 MDA drugs - Total
2. No. of individual examined found positive for 2. No. of patients seen - Total
lymphatic filariasis - Total 0 3. No. of suspected cases seen
3. No. of lymphatic filariasis cases examined with 4. No. acute clinically diagnosed cases -
manifestation of either lymphedema,hydrocele, Total
elephantiasis - Total
0 5. No. of confirmed acute cases - Total
6. No. of chronic clinically diagnosed
cases - Total
Section F. _________________________
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
 ___JANUARY_____ YEAR: ____2020___

M1
AGPAKO__________________________
_________________________
_________________________

BRGY
________________________
________________________
r submission to RHU/MHC

Services and Deworming for Women of Reproductive Age

Total A3. Deworming Services SES Total

Col. 3) (Col. 1) (Col. 2) (Col. 3)

NHTS Non-NHTS
1. No. of women 20-49 years old given 2 doses of
15 deworming drugs - Total
0 0 0
15
0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
on B. Maternal Care and Services
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

a. Number of pregnant women seen in the

first trimester who have normal BMI -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of pregnant women seen in the first
trimester who have low BMI - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

7. No. of pregnant women given iodine

capsules – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
8. No. of pregnant women given one dose
of deworming tablet - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
9. No. of pregnant women screened for
syphilis - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
10. No. of pregnant women tested positive
for syphilis - Total

0 0 0 0
 • NHTS 0
• Non-NHTS 0
11. No. of pregnant women screened for
Hepatitis B - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
18. No. of deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
19. No. of live births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20a. No. of live births with normal birth
weight - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20b. No. of live births with low birth weight
- Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
20c. No. of live births with unknown birth
weight- Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
21. No. of deliveries attended by skilled
health professionals - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col 3)  (Col. 4)
rks Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

24a. No. of deliveries in public health

facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
24b. No. of deliveries in private health
facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
25. No. of non-facility-based deliveries -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
26a. No. of vaginal deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
26b. No. of deliveries by cesarean
section – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
27a. No. of full-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
27b. No. of pre-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B3. Postpartum and Newborn Care
28. No. of postpartum women together
with their newborn who completed at
least 2 postpartum check-ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
 29. No. of postpartum women who
completed iron with folic acid
supplementation - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
30. No. of postpartum women with
Vitamin A supplementation – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
ction C. Child Care and Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)

epB 3 - Total 0 0 0 11. PCV 1 - Total 0 0

0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 12. PCV 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 13. PCV 3 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 14. MMR 1 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
0 0 0 15. MMR 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
1 (November) - Total 0 0 0 20. Td, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
e 1 (November) - Total 0 0 0 21. MR, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

34. Children 12-23 mos. who completed

1 mos. old seen - Total
MNP supplementation - Total
0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
 1 mos. given 1 dose of
35. Children 0-59 mos. seen - Total
100,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos seen - Total 0 0 0 36. Stunted - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos. old given 2
37. Wasted - Total
tamin A 200,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
1 months old who completed
38. Overweight/Obese - Total
lementation - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS

2-23 mos. seen - Total 39. Normal - Total

0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col. 1) (Col 2) (Col 3)

y/o dewormed (2 doses) - 43. Adolescents, 10-19 y/o dewormed

0 0 0 (2 doses) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

ren 12-59 mos. old 50. Diarrhea cases 0-59 mos. received
itamin A - Total 0 0 0 ORS w/ zinc - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old seen 51. Pneumonia cases 0-59 mos. old
0 0 0 seen - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old 52. Pneumonia cases 0-59 mos. old
ORS - Total 0 0 0 completed treatment - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
 To be submitted Quarterly
ous Disease Prevention and Control Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
miasis Prevention and Control E2. Schistosomiasis Prevention and Control (Con't.)
le 5-65 y/o who ingested 7. No. confirmed chronic cases - Total
- Total 0
nts seen - Total 0 8. No. of confirmed cases (acute and
ected cases seen 0 chronic) - Total
clinically diagnosed cases - 9. No. of cases treated - Total
0
rmed acute cases - Total 0 10. No. of confirmed chronic cases
nic clinically diagnosed referred to a hospital facility - Total
al 0
_________________________________________
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
M1
RGY
Total

(Col. 3)

New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
 0 0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0 0
0
0
0 0
0
0
0 0
0
0
 0 0
0
0

Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
 Total
(Col 4)

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Total
(Col 4)
0
0
0
0
0
0

0
0
0
 0
0
0
0
0
0

0
0
0

0
0
0

0
0
0
Total
(Col 4)

0
0
0

0
0
0

0
0
0

0
0
0
 Total
(Col 4)
't.)

Total
(Col 4)
 FHSIS REPORT for the MONTH: ___JANUARY_____
Name of Barangay: _____TAGPAKO_________
Name of BHS: _______________________
Name of Municipality/City: _______________________
Name of Province: ________________________
Projected Population of the Year: _______________________
For submission to RHU/MHC

Section A. Family Planning Services and Dewor

A1. Modern FP Unmet Need Age Total

(Col. 1) (Col. 2) (Col. 3)

10-14 15-19 20-49
1. No. of WRA with unmet
need for modern FP - Total 5 5 5
15
• NHTS 5 5 5 15
• Non-NHTS 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
a. Female Sterilization/ BTL - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
b. Male Sterilization/ NSV-Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
c. Condom - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d. Pills - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
 d.1 Pills-POP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d.2 Pills-COC - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
e. Injectables (DMPA/ POI) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
f. Implant - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g. IUD (IUD-I and IUD-PP) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.1 IUD-I- Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.2 IUD-PP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
h. NFP-LAM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
i. NFP-BBT - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
j. NFP-CMM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
k. NFP-STM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
l. NFP-SDM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
m. Total Current Users 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
Section B. Maternal Care
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
1. No. of pregnant women w/
at least 4 prenatal check-
ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
2. No. of pregnant women
assessed of their nutritional
status during the 1st tri. -Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
c. No. of pregnant women
seen in the first trimester
who have high BMI - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
3. No. of pregnant women for
the first time given 2 doses of
Td vaccination - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
4. No. of pregnant women for
the 2nd or more times given
at least 3 doses of Td
vaccination (Td2 Plus) - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
5. No. of pregnant women who
completed the dose of iron
with folic acid
supplementation - Total 0 0 0 0
 • NHTS 0
• Non-NHTS 0
6. No. of pregnant women who
completed doses of calcium
carbonate supplementation -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
12. No. of pregnant women
tested positive for Hepatitis
B - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
13. No. of pregnant women
screened for HIV - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
14. No. of pregnant women
tested for CBC or Hgb&Hct
count - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
15. No. of pregnant women
tested for CBC or Hgb&Hct
count diagnosed with
anemia - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
16. No. of pregnant women
screened for gestational
diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
17.   No. of pregnant women
tested positive for
gestational diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col 3)  (Col. 4)
 Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
a. No. of deliveries attended
by a doctor - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by a nurse – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
c. No. of deliveries attended
by midwives - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
22. No. of deliveries attended by
non-skilled health
professionals - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
a. No. of deliveries attended
by Hilot/TBA - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by others - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
23. No. of health facility-based
deliveries - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
27c. No. of fetal deaths - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
27d. No. of abortion/
miscarriage - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0

Section C. Child Care a

Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
C1. Immunization Services
1. CPAB - Total 0 0 0 6. DPT-HiB-HepB 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
2. BCG - Total 0 0 0 7. OPV 1 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
3. HepB, within 24 hours. - Total 0 0 0 8. OPV 2 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
4. DPT-HiB-HepB 1 - Total 0 0 0 9. OPV 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
5. DPT-HiB-HepB 2 - Total 0 0 0 10. IPV - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
16. FIC - Total 0 0 0 18. Td, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
17. CIC - Total 0 0 0 19. MR, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
C2. Nutrition Services
22. Newborns initiated on breastfeeding
immediately after birth lasting to 90 mins - 28. Infants 6-11 mos. old seen - Total
Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
23. Preterm/LBW infants given iron 29. Infants 6-11 mos. given 1 dose of
supplementation - Total 0 0 0 Vitamin A 100,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
24. Infants 6 mos. old seen - Total 0 0 0 30. Children 12-59 mos seen - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
25. Infants exclusively breastfed until 6th month - 31. Children 12-59 mos. old given 2
Total 0 0 0 doses of Vitamin A 200,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
26. Infants 6 mos. old initiated to complementary 32. Infant 6-11 months old who completed
feeding with continued breastfeeding - Total 0 0 0 MNP supplementation - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
27. Infants 6 mos. old initiated to complementary
feeding but no longer or never been breastfed 33. Children 12-23 mos. seen - Total
- Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
0
40. 1-19 y/o given 2 doses of deworming drug - 42. SAC, 5-9 y/o dewormed (2 doses) -
Total 0 0 0 Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
41. PSAC, 1-4 y/o dewormed (2 doses) - Total 0 0 0
• NHTS 0
• Non-NHTS 0
0
44. Sick Infants 6-11 mos. old seen - Total 47. Sick Children 12-59 mos. old
0 0 0 received Vitamin A - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
45. Sick Infants 6-11 mos. old received 48. Diarrhea cases 0-59 months old seen
Vitamin A - Total 0 0 0 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
49. Diarrhea cases 0-59 months old
46. Sick Children 12-59 mos. old seen - Total
0 0 0 received ORS - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
 To be submitted Qua
Section E. Infectious Disease Preven
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
E1. Filariasis Prevention and Control E2. Schistosomiasis Prevention and Contro
1. No. of individual examined for lymphatic 1. No. of people 5-65 y/o who ingested
filariasis - Total 0 MDA drugs - Total
2. No. of individual examined found positive for 2. No. of patients seen - Total
lymphatic filariasis - Total 0 3. No. of suspected cases seen
3. No. of lymphatic filariasis cases examined with 4. No. acute clinically diagnosed cases -
manifestation of either lymphedema,hydrocele, Total
elephantiasis - Total
0 5. No. of confirmed acute cases - Total
6. No. of chronic clinically diagnosed
cases - Total
Section F. _________________________
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
 ___JANUARY_____ YEAR: ____2020___

M1
AGPAKO__________________________
_________________________
_________________________

BRGY
________________________
________________________
r submission to RHU/MHC

Services and Deworming for Women of Reproductive Age

Total A3. Deworming Services SES Total

Col. 3) (Col. 1) (Col. 2) (Col. 3)

NHTS Non-NHTS
1. No. of women 20-49 years old given 2 doses of
15 deworming drugs - Total
0 0 0
15
0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
on B. Maternal Care and Services
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

a. Number of pregnant women seen in the

first trimester who have normal BMI -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of pregnant women seen in the first
trimester who have low BMI - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

7. No. of pregnant women given iodine

capsules – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
8. No. of pregnant women given one dose
of deworming tablet - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
9. No. of pregnant women screened for
syphilis - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
10. No. of pregnant women tested positive
for syphilis - Total

0 0 0 0
 • NHTS 0
• Non-NHTS 0
11. No. of pregnant women screened for
Hepatitis B - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
18. No. of deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
19. No. of live births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20a. No. of live births with normal birth
weight - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20b. No. of live births with low birth weight
- Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
20c. No. of live births with unknown birth
weight- Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
21. No. of deliveries attended by skilled
health professionals - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col 3)  (Col. 4)
rks Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

24a. No. of deliveries in public health

facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
24b. No. of deliveries in private health
facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
25. No. of non-facility-based deliveries -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
26a. No. of vaginal deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
26b. No. of deliveries by cesarean
section – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
27a. No. of full-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
27b. No. of pre-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B3. Postpartum and Newborn Care
28. No. of postpartum women together
with their newborn who completed at
least 2 postpartum check-ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
 29. No. of postpartum women who
completed iron with folic acid
supplementation - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
30. No. of postpartum women with
Vitamin A supplementation – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
ction C. Child Care and Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)

epB 3 - Total 0 0 0 11. PCV 1 - Total 0 0

0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 12. PCV 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 13. PCV 3 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 14. MMR 1 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
0 0 0 15. MMR 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
1 (November) - Total 0 0 0 20. Td, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
e 1 (November) - Total 0 0 0 21. MR, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

34. Children 12-23 mos. who completed

1 mos. old seen - Total
MNP supplementation - Total
0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
 1 mos. given 1 dose of
35. Children 0-59 mos. seen - Total
100,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos seen - Total 0 0 0 36. Stunted - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos. old given 2
37. Wasted - Total
tamin A 200,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
1 months old who completed
38. Overweight/Obese - Total
lementation - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS

2-23 mos. seen - Total 39. Normal - Total

0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col. 1) (Col 2) (Col 3)

y/o dewormed (2 doses) - 43. Adolescents, 10-19 y/o dewormed

0 0 0 (2 doses) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

ren 12-59 mos. old 50. Diarrhea cases 0-59 mos. received
itamin A - Total 0 0 0 ORS w/ zinc - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old seen 51. Pneumonia cases 0-59 mos. old
0 0 0 seen - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old 52. Pneumonia cases 0-59 mos. old
ORS - Total 0 0 0 completed treatment - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
 To be submitted Quarterly
ous Disease Prevention and Control Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
miasis Prevention and Control E2. Schistosomiasis Prevention and Control (Con't.)
le 5-65 y/o who ingested 7. No. confirmed chronic cases - Total
- Total 0
nts seen - Total 0 8. No. of confirmed cases (acute and
ected cases seen 0 chronic) - Total
clinically diagnosed cases - 9. No. of cases treated - Total
0
rmed acute cases - Total 0 10. No. of confirmed chronic cases
nic clinically diagnosed referred to a hospital facility - Total
al 0
_________________________________________
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
M1
RGY
Total

(Col. 3)

New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
 0 0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0 0
0
0
0 0
0
0
0 0
0
0
 0 0
0
0

Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
 Total
(Col 4)

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Total
(Col 4)
0
0
0
0
0
0

0
0
0
 0
0
0
0
0
0

0
0
0

0
0
0

0
0
0
Total
(Col 4)

0
0
0

0
0
0

0
0
0

0
0
0
 Total
(Col 4)
't.)

Total
(Col 4)
 FHSIS REPORT for the MONTH: ___JANUARY_____
Name of Barangay: _____TAGPAKO_________
Name of BHS: _______________________
Name of Municipality/City: _______________________
Name of Province: ________________________
Projected Population of the Year: _______________________
For submission to RHU/MHC

Section A. Family Planning Services and Dewor

A1. Modern FP Unmet Need Age Total

(Col. 1) (Col. 2) (Col. 3)

10-14 15-19 20-49
1. No. of WRA with unmet
need for modern FP - Total 5 5 5
15
• NHTS 5 5 5 15
• Non-NHTS 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
a. Female Sterilization/ BTL - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
b. Male Sterilization/ NSV-Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
c. Condom - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d. Pills - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
 d.1 Pills-POP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d.2 Pills-COC - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
e. Injectables (DMPA/ POI) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
f. Implant - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g. IUD (IUD-I and IUD-PP) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.1 IUD-I- Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.2 IUD-PP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
h. NFP-LAM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
i. NFP-BBT - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
j. NFP-CMM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
k. NFP-STM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
l. NFP-SDM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
m. Total Current Users 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
Section B. Maternal Care
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
1. No. of pregnant women w/
at least 4 prenatal check-
ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
2. No. of pregnant women
assessed of their nutritional
status during the 1st tri. -Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
c. No. of pregnant women
seen in the first trimester
who have high BMI - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
3. No. of pregnant women for
the first time given 2 doses of
Td vaccination - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
4. No. of pregnant women for
the 2nd or more times given
at least 3 doses of Td
vaccination (Td2 Plus) - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
5. No. of pregnant women who
completed the dose of iron
with folic acid
supplementation - Total 0 0 0 0
 • NHTS 0
• Non-NHTS 0
6. No. of pregnant women who
completed doses of calcium
carbonate supplementation -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
12. No. of pregnant women
tested positive for Hepatitis
B - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
13. No. of pregnant women
screened for HIV - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
14. No. of pregnant women
tested for CBC or Hgb&Hct
count - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
15. No. of pregnant women
tested for CBC or Hgb&Hct
count diagnosed with
anemia - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
16. No. of pregnant women
screened for gestational
diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
17.   No. of pregnant women
tested positive for
gestational diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col 3)  (Col. 4)
 Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
a. No. of deliveries attended
by a doctor - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by a nurse – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
c. No. of deliveries attended
by midwives - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
22. No. of deliveries attended by
non-skilled health
professionals - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
a. No. of deliveries attended
by Hilot/TBA - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by others - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
23. No. of health facility-based
deliveries - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
27c. No. of fetal deaths - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
27d. No. of abortion/
miscarriage - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0

Section C. Child Care a

Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
C1. Immunization Services
1. CPAB - Total 0 0 0 6. DPT-HiB-HepB 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
2. BCG - Total 0 0 0 7. OPV 1 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
3. HepB, within 24 hours. - Total 0 0 0 8. OPV 2 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
4. DPT-HiB-HepB 1 - Total 0 0 0 9. OPV 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
5. DPT-HiB-HepB 2 - Total 0 0 0 10. IPV - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
16. FIC - Total 0 0 0 18. Td, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
17. CIC - Total 0 0 0 19. MR, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
C2. Nutrition Services
22. Newborns initiated on breastfeeding
immediately after birth lasting to 90 mins - 28. Infants 6-11 mos. old seen - Total
Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
23. Preterm/LBW infants given iron 29. Infants 6-11 mos. given 1 dose of
supplementation - Total 0 0 0 Vitamin A 100,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
24. Infants 6 mos. old seen - Total 0 0 0 30. Children 12-59 mos seen - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
25. Infants exclusively breastfed until 6th month - 31. Children 12-59 mos. old given 2
Total 0 0 0 doses of Vitamin A 200,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
26. Infants 6 mos. old initiated to complementary 32. Infant 6-11 months old who completed
feeding with continued breastfeeding - Total 0 0 0 MNP supplementation - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
27. Infants 6 mos. old initiated to complementary
feeding but no longer or never been breastfed 33. Children 12-23 mos. seen - Total
- Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
0
40. 1-19 y/o given 2 doses of deworming drug - 42. SAC, 5-9 y/o dewormed (2 doses) -
Total 0 0 0 Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
41. PSAC, 1-4 y/o dewormed (2 doses) - Total 0 0 0
• NHTS 0
• Non-NHTS 0
0
44. Sick Infants 6-11 mos. old seen - Total 47. Sick Children 12-59 mos. old
0 0 0 received Vitamin A - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
45. Sick Infants 6-11 mos. old received 48. Diarrhea cases 0-59 months old seen
Vitamin A - Total 0 0 0 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
49. Diarrhea cases 0-59 months old
46. Sick Children 12-59 mos. old seen - Total
0 0 0 received ORS - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
 To be submitted Qua
Section E. Infectious Disease Preven
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
E1. Filariasis Prevention and Control E2. Schistosomiasis Prevention and Contro
1. No. of individual examined for lymphatic 1. No. of people 5-65 y/o who ingested
filariasis - Total 0 MDA drugs - Total
2. No. of individual examined found positive for 2. No. of patients seen - Total
lymphatic filariasis - Total 0 3. No. of suspected cases seen
3. No. of lymphatic filariasis cases examined with 4. No. acute clinically diagnosed cases -
manifestation of either lymphedema,hydrocele, Total
elephantiasis - Total
0 5. No. of confirmed acute cases - Total
6. No. of chronic clinically diagnosed
cases - Total
Section F. _________________________
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
 ___JANUARY_____ YEAR: ____2020___

M1
AGPAKO__________________________
_________________________
_________________________

BRGY
________________________
________________________
r submission to RHU/MHC

Services and Deworming for Women of Reproductive Age

Total A3. Deworming Services SES Total

Col. 3) (Col. 1) (Col. 2) (Col. 3)

NHTS Non-NHTS
1. No. of women 20-49 years old given 2 doses of
15 deworming drugs - Total
0 0 0
15
0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
on B. Maternal Care and Services
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

a. Number of pregnant women seen in the

first trimester who have normal BMI -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of pregnant women seen in the first
trimester who have low BMI - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

7. No. of pregnant women given iodine

capsules – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
8. No. of pregnant women given one dose
of deworming tablet - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
9. No. of pregnant women screened for
syphilis - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
10. No. of pregnant women tested positive
for syphilis - Total

0 0 0 0
 • NHTS 0
• Non-NHTS 0
11. No. of pregnant women screened for
Hepatitis B - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
18. No. of deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
19. No. of live births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20a. No. of live births with normal birth
weight - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20b. No. of live births with low birth weight
- Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
20c. No. of live births with unknown birth
weight- Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
21. No. of deliveries attended by skilled
health professionals - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col 3)  (Col. 4)
rks Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

24a. No. of deliveries in public health

facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
24b. No. of deliveries in private health
facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
25. No. of non-facility-based deliveries -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
26a. No. of vaginal deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
26b. No. of deliveries by cesarean
section – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
27a. No. of full-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
27b. No. of pre-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B3. Postpartum and Newborn Care
28. No. of postpartum women together
with their newborn who completed at
least 2 postpartum check-ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
 29. No. of postpartum women who
completed iron with folic acid
supplementation - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
30. No. of postpartum women with
Vitamin A supplementation – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
ction C. Child Care and Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)

epB 3 - Total 0 0 0 11. PCV 1 - Total 0 0

0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 12. PCV 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 13. PCV 3 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 14. MMR 1 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
0 0 0 15. MMR 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
1 (November) - Total 0 0 0 20. Td, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
e 1 (November) - Total 0 0 0 21. MR, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

34. Children 12-23 mos. who completed

1 mos. old seen - Total
MNP supplementation - Total
0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
 1 mos. given 1 dose of
35. Children 0-59 mos. seen - Total
100,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos seen - Total 0 0 0 36. Stunted - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos. old given 2
37. Wasted - Total
tamin A 200,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
1 months old who completed
38. Overweight/Obese - Total
lementation - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS

2-23 mos. seen - Total 39. Normal - Total

0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col. 1) (Col 2) (Col 3)

y/o dewormed (2 doses) - 43. Adolescents, 10-19 y/o dewormed

0 0 0 (2 doses) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

ren 12-59 mos. old 50. Diarrhea cases 0-59 mos. received
itamin A - Total 0 0 0 ORS w/ zinc - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old seen 51. Pneumonia cases 0-59 mos. old
0 0 0 seen - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old 52. Pneumonia cases 0-59 mos. old
ORS - Total 0 0 0 completed treatment - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
 To be submitted Quarterly
ous Disease Prevention and Control Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
miasis Prevention and Control E2. Schistosomiasis Prevention and Control (Con't.)
le 5-65 y/o who ingested 7. No. confirmed chronic cases - Total
- Total 0
nts seen - Total 0 8. No. of confirmed cases (acute and
ected cases seen 0 chronic) - Total
clinically diagnosed cases - 9. No. of cases treated - Total
0
rmed acute cases - Total 0 10. No. of confirmed chronic cases
nic clinically diagnosed referred to a hospital facility - Total
al 0
_________________________________________
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
M1
RGY
Total

(Col. 3)

New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
 0 0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0 0
0
0
0 0
0
0
0 0
0
0
 0 0
0
0

Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
 Total
(Col 4)

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Total
(Col 4)
0
0
0
0
0
0

0
0
0
 0
0
0
0
0
0

0
0
0

0
0
0

0
0
0
Total
(Col 4)

0
0
0

0
0
0

0
0
0

0
0
0
 Total
(Col 4)
't.)

Total
(Col 4)
 FHSIS REPORT for the MONTH: ___JANUARY_____
Name of Barangay: _____TAGPAKO_________
Name of BHS: _______________________
Name of Municipality/City: _______________________
Name of Province: ________________________
Projected Population of the Year: _______________________
For submission to RHU/MHC

Section A. Family Planning Services and Dewor

A1. Modern FP Unmet Need Age Total

(Col. 1) (Col. 2) (Col. 3)

10-14 15-19 20-49
1. No. of WRA with unmet
need for modern FP - Total 5 5 5
15
• NHTS 5 5 5 15
• Non-NHTS 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
a. Female Sterilization/ BTL - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
b. Male Sterilization/ NSV-Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
c. Condom - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d. Pills - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
 d.1 Pills-POP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d.2 Pills-COC - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
e. Injectables (DMPA/ POI) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
f. Implant - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g. IUD (IUD-I and IUD-PP) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.1 IUD-I- Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.2 IUD-PP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
h. NFP-LAM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
i. NFP-BBT - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
j. NFP-CMM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
k. NFP-STM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
l. NFP-SDM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
m. Total Current Users 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
Section B. Maternal Care
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
1. No. of pregnant women w/
at least 4 prenatal check-
ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
2. No. of pregnant women
assessed of their nutritional
status during the 1st tri. -Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
c. No. of pregnant women
seen in the first trimester
who have high BMI - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
3. No. of pregnant women for
the first time given 2 doses of
Td vaccination - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
4. No. of pregnant women for
the 2nd or more times given
at least 3 doses of Td
vaccination (Td2 Plus) - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
5. No. of pregnant women who
completed the dose of iron
with folic acid
supplementation - Total 0 0 0 0
 • NHTS 0
• Non-NHTS 0
6. No. of pregnant women who
completed doses of calcium
carbonate supplementation -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
12. No. of pregnant women
tested positive for Hepatitis
B - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
13. No. of pregnant women
screened for HIV - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
14. No. of pregnant women
tested for CBC or Hgb&Hct
count - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
15. No. of pregnant women
tested for CBC or Hgb&Hct
count diagnosed with
anemia - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
16. No. of pregnant women
screened for gestational
diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
17.   No. of pregnant women
tested positive for
gestational diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col 3)  (Col. 4)
 Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
a. No. of deliveries attended
by a doctor - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by a nurse – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
c. No. of deliveries attended
by midwives - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
22. No. of deliveries attended by
non-skilled health
professionals - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
a. No. of deliveries attended
by Hilot/TBA - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by others - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
23. No. of health facility-based
deliveries - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
27c. No. of fetal deaths - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
27d. No. of abortion/
miscarriage - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0

Section C. Child Care a

Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
C1. Immunization Services
1. CPAB - Total 0 0 0 6. DPT-HiB-HepB 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
2. BCG - Total 0 0 0 7. OPV 1 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
3. HepB, within 24 hours. - Total 0 0 0 8. OPV 2 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
4. DPT-HiB-HepB 1 - Total 0 0 0 9. OPV 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
5. DPT-HiB-HepB 2 - Total 0 0 0 10. IPV - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
16. FIC - Total 0 0 0 18. Td, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
17. CIC - Total 0 0 0 19. MR, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
C2. Nutrition Services
22. Newborns initiated on breastfeeding
immediately after birth lasting to 90 mins - 28. Infants 6-11 mos. old seen - Total
Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
23. Preterm/LBW infants given iron 29. Infants 6-11 mos. given 1 dose of
supplementation - Total 0 0 0 Vitamin A 100,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
24. Infants 6 mos. old seen - Total 0 0 0 30. Children 12-59 mos seen - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
25. Infants exclusively breastfed until 6th month - 31. Children 12-59 mos. old given 2
Total 0 0 0 doses of Vitamin A 200,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
26. Infants 6 mos. old initiated to complementary 32. Infant 6-11 months old who completed
feeding with continued breastfeeding - Total 0 0 0 MNP supplementation - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
27. Infants 6 mos. old initiated to complementary
feeding but no longer or never been breastfed 33. Children 12-23 mos. seen - Total
- Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
0
40. 1-19 y/o given 2 doses of deworming drug - 42. SAC, 5-9 y/o dewormed (2 doses) -
Total 0 0 0 Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
41. PSAC, 1-4 y/o dewormed (2 doses) - Total 0 0 0
• NHTS 0
• Non-NHTS 0
0
44. Sick Infants 6-11 mos. old seen - Total 47. Sick Children 12-59 mos. old
0 0 0 received Vitamin A - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
45. Sick Infants 6-11 mos. old received 48. Diarrhea cases 0-59 months old seen
Vitamin A - Total 0 0 0 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
49. Diarrhea cases 0-59 months old
46. Sick Children 12-59 mos. old seen - Total
0 0 0 received ORS - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
 To be submitted Qua
Section E. Infectious Disease Preven
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
E1. Filariasis Prevention and Control E2. Schistosomiasis Prevention and Contro
1. No. of individual examined for lymphatic 1. No. of people 5-65 y/o who ingested
filariasis - Total 0 MDA drugs - Total
2. No. of individual examined found positive for 2. No. of patients seen - Total
lymphatic filariasis - Total 0 3. No. of suspected cases seen
3. No. of lymphatic filariasis cases examined with 4. No. acute clinically diagnosed cases -
manifestation of either lymphedema,hydrocele, Total
elephantiasis - Total
0 5. No. of confirmed acute cases - Total
6. No. of chronic clinically diagnosed
cases - Total
Section F. _________________________
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
 ___JANUARY_____ YEAR: ____2020___

M1
AGPAKO__________________________
_________________________
_________________________

BRGY
________________________
________________________
r submission to RHU/MHC

Services and Deworming for Women of Reproductive Age

Total A3. Deworming Services SES Total

Col. 3) (Col. 1) (Col. 2) (Col. 3)

NHTS Non-NHTS
1. No. of women 20-49 years old given 2 doses of
15 deworming drugs - Total
0 0 0
15
0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
on B. Maternal Care and Services
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

a. Number of pregnant women seen in the

first trimester who have normal BMI -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of pregnant women seen in the first
trimester who have low BMI - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

7. No. of pregnant women given iodine

capsules – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
8. No. of pregnant women given one dose
of deworming tablet - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
9. No. of pregnant women screened for
syphilis - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
10. No. of pregnant women tested positive
for syphilis - Total

0 0 0 0
 • NHTS 0
• Non-NHTS 0
11. No. of pregnant women screened for
Hepatitis B - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
18. No. of deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
19. No. of live births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20a. No. of live births with normal birth
weight - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20b. No. of live births with low birth weight
- Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
20c. No. of live births with unknown birth
weight- Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
21. No. of deliveries attended by skilled
health professionals - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col 3)  (Col. 4)
rks Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

24a. No. of deliveries in public health

facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
24b. No. of deliveries in private health
facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
25. No. of non-facility-based deliveries -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
26a. No. of vaginal deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
26b. No. of deliveries by cesarean
section – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
27a. No. of full-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
27b. No. of pre-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B3. Postpartum and Newborn Care
28. No. of postpartum women together
with their newborn who completed at
least 2 postpartum check-ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
 29. No. of postpartum women who
completed iron with folic acid
supplementation - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
30. No. of postpartum women with
Vitamin A supplementation – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
ction C. Child Care and Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)

epB 3 - Total 0 0 0 11. PCV 1 - Total 0 0

0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 12. PCV 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 13. PCV 3 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 14. MMR 1 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
0 0 0 15. MMR 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
1 (November) - Total 0 0 0 20. Td, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
e 1 (November) - Total 0 0 0 21. MR, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

34. Children 12-23 mos. who completed

1 mos. old seen - Total
MNP supplementation - Total
0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
 1 mos. given 1 dose of
35. Children 0-59 mos. seen - Total
100,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos seen - Total 0 0 0 36. Stunted - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos. old given 2
37. Wasted - Total
tamin A 200,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
1 months old who completed
38. Overweight/Obese - Total
lementation - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS

2-23 mos. seen - Total 39. Normal - Total

0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col. 1) (Col 2) (Col 3)

y/o dewormed (2 doses) - 43. Adolescents, 10-19 y/o dewormed

0 0 0 (2 doses) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

ren 12-59 mos. old 50. Diarrhea cases 0-59 mos. received
itamin A - Total 0 0 0 ORS w/ zinc - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old seen 51. Pneumonia cases 0-59 mos. old
0 0 0 seen - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old 52. Pneumonia cases 0-59 mos. old
ORS - Total 0 0 0 completed treatment - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
 To be submitted Quarterly
ous Disease Prevention and Control Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
miasis Prevention and Control E2. Schistosomiasis Prevention and Control (Con't.)
le 5-65 y/o who ingested 7. No. confirmed chronic cases - Total
- Total 0
nts seen - Total 0 8. No. of confirmed cases (acute and
ected cases seen 0 chronic) - Total
clinically diagnosed cases - 9. No. of cases treated - Total
0
rmed acute cases - Total 0 10. No. of confirmed chronic cases
nic clinically diagnosed referred to a hospital facility - Total
al 0
_________________________________________
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
M1
RGY
Total

(Col. 3)

New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
 0 0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0 0
0
0
0 0
0
0
0 0
0
0
 0 0
0
0

Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
 Total
(Col 4)

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Total
(Col 4)
0
0
0
0
0
0

0
0
0
 0
0
0
0
0
0

0
0
0

0
0
0

0
0
0
Total
(Col 4)

0
0
0

0
0
0

0
0
0

0
0
0
 Total
(Col 4)
't.)

Total
(Col 4)
 FHSIS REPORT for the MONTH: ___JANUARY_____
Name of Barangay: _____TAGPAKO_________
Name of BHS: _______________________
Name of Municipality/City: _______________________
Name of Province: ________________________
Projected Population of the Year: _______________________
For submission to RHU/MHC

Section A. Family Planning Services and Dewor

A1. Modern FP Unmet Need Age Total

(Col. 1) (Col. 2) (Col. 3)

10-14 15-19 20-49
1. No. of WRA with unmet
need for modern FP - Total 5 5 5
15
• NHTS 5 5 5 15
• Non-NHTS 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
a. Female Sterilization/ BTL - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
b. Male Sterilization/ NSV-Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
c. Condom - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d. Pills - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
 d.1 Pills-POP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d.2 Pills-COC - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
e. Injectables (DMPA/ POI) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
f. Implant - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g. IUD (IUD-I and IUD-PP) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.1 IUD-I- Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.2 IUD-PP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
h. NFP-LAM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
i. NFP-BBT - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
j. NFP-CMM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
k. NFP-STM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
l. NFP-SDM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
m. Total Current Users 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
Section B. Maternal Care
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
1. No. of pregnant women w/
at least 4 prenatal check-
ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
2. No. of pregnant women
assessed of their nutritional
status during the 1st tri. -Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
c. No. of pregnant women
seen in the first trimester
who have high BMI - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
3. No. of pregnant women for
the first time given 2 doses of
Td vaccination - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
4. No. of pregnant women for
the 2nd or more times given
at least 3 doses of Td
vaccination (Td2 Plus) - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
5. No. of pregnant women who
completed the dose of iron
with folic acid
supplementation - Total 0 0 0 0
 • NHTS 0
• Non-NHTS 0
6. No. of pregnant women who
completed doses of calcium
carbonate supplementation -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
12. No. of pregnant women
tested positive for Hepatitis
B - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
13. No. of pregnant women
screened for HIV - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
14. No. of pregnant women
tested for CBC or Hgb&Hct
count - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
15. No. of pregnant women
tested for CBC or Hgb&Hct
count diagnosed with
anemia - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
16. No. of pregnant women
screened for gestational
diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
17.   No. of pregnant women
tested positive for
gestational diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col 3)  (Col. 4)
 Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
a. No. of deliveries attended
by a doctor - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by a nurse – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
c. No. of deliveries attended
by midwives - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
22. No. of deliveries attended by
non-skilled health
professionals - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
a. No. of deliveries attended
by Hilot/TBA - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by others - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
23. No. of health facility-based
deliveries - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
27c. No. of fetal deaths - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
27d. No. of abortion/
miscarriage - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0

Section C. Child Care a

Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
C1. Immunization Services
1. CPAB - Total 0 0 0 6. DPT-HiB-HepB 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
2. BCG - Total 0 0 0 7. OPV 1 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
3. HepB, within 24 hours. - Total 0 0 0 8. OPV 2 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
4. DPT-HiB-HepB 1 - Total 0 0 0 9. OPV 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
5. DPT-HiB-HepB 2 - Total 0 0 0 10. IPV - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
16. FIC - Total 0 0 0 18. Td, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
17. CIC - Total 0 0 0 19. MR, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
C2. Nutrition Services
22. Newborns initiated on breastfeeding
immediately after birth lasting to 90 mins - 28. Infants 6-11 mos. old seen - Total
Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
23. Preterm/LBW infants given iron 29. Infants 6-11 mos. given 1 dose of
supplementation - Total 0 0 0 Vitamin A 100,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
24. Infants 6 mos. old seen - Total 0 0 0 30. Children 12-59 mos seen - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
25. Infants exclusively breastfed until 6th month - 31. Children 12-59 mos. old given 2
Total 0 0 0 doses of Vitamin A 200,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
26. Infants 6 mos. old initiated to complementary 32. Infant 6-11 months old who completed
feeding with continued breastfeeding - Total 0 0 0 MNP supplementation - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
27. Infants 6 mos. old initiated to complementary
feeding but no longer or never been breastfed 33. Children 12-23 mos. seen - Total
- Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
0
40. 1-19 y/o given 2 doses of deworming drug - 42. SAC, 5-9 y/o dewormed (2 doses) -
Total 0 0 0 Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
41. PSAC, 1-4 y/o dewormed (2 doses) - Total 0 0 0
• NHTS 0
• Non-NHTS 0
0
44. Sick Infants 6-11 mos. old seen - Total 47. Sick Children 12-59 mos. old
0 0 0 received Vitamin A - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
45. Sick Infants 6-11 mos. old received 48. Diarrhea cases 0-59 months old seen
Vitamin A - Total 0 0 0 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
49. Diarrhea cases 0-59 months old
46. Sick Children 12-59 mos. old seen - Total
0 0 0 received ORS - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
 To be submitted Qua
Section E. Infectious Disease Preven
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
E1. Filariasis Prevention and Control E2. Schistosomiasis Prevention and Contro
1. No. of individual examined for lymphatic 1. No. of people 5-65 y/o who ingested
filariasis - Total 0 MDA drugs - Total
2. No. of individual examined found positive for 2. No. of patients seen - Total
lymphatic filariasis - Total 0 3. No. of suspected cases seen
3. No. of lymphatic filariasis cases examined with 4. No. acute clinically diagnosed cases -
manifestation of either lymphedema,hydrocele, Total
elephantiasis - Total
0 5. No. of confirmed acute cases - Total
6. No. of chronic clinically diagnosed
cases - Total
Section F. _________________________
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
 ___JANUARY_____ YEAR: ____2020___

M1
AGPAKO__________________________
_________________________
_________________________

BRGY
________________________
________________________
r submission to RHU/MHC

Services and Deworming for Women of Reproductive Age

Total A3. Deworming Services SES Total

Col. 3) (Col. 1) (Col. 2) (Col. 3)

NHTS Non-NHTS
1. No. of women 20-49 years old given 2 doses of
15 deworming drugs - Total
0 0 0
15
0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
on B. Maternal Care and Services
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

a. Number of pregnant women seen in the

first trimester who have normal BMI -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of pregnant women seen in the first
trimester who have low BMI - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

7. No. of pregnant women given iodine

capsules – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
8. No. of pregnant women given one dose
of deworming tablet - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
9. No. of pregnant women screened for
syphilis - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
10. No. of pregnant women tested positive
for syphilis - Total

0 0 0 0
 • NHTS 0
• Non-NHTS 0
11. No. of pregnant women screened for
Hepatitis B - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
18. No. of deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
19. No. of live births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20a. No. of live births with normal birth
weight - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20b. No. of live births with low birth weight
- Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
20c. No. of live births with unknown birth
weight- Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
21. No. of deliveries attended by skilled
health professionals - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col 3)  (Col. 4)
rks Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

24a. No. of deliveries in public health

facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
24b. No. of deliveries in private health
facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
25. No. of non-facility-based deliveries -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
26a. No. of vaginal deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
26b. No. of deliveries by cesarean
section – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
27a. No. of full-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
27b. No. of pre-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B3. Postpartum and Newborn Care
28. No. of postpartum women together
with their newborn who completed at
least 2 postpartum check-ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
 29. No. of postpartum women who
completed iron with folic acid
supplementation - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
30. No. of postpartum women with
Vitamin A supplementation – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
ction C. Child Care and Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)

epB 3 - Total 0 0 0 11. PCV 1 - Total 0 0

0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 12. PCV 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 13. PCV 3 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 14. MMR 1 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
0 0 0 15. MMR 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
1 (November) - Total 0 0 0 20. Td, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
e 1 (November) - Total 0 0 0 21. MR, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

34. Children 12-23 mos. who completed

1 mos. old seen - Total
MNP supplementation - Total
0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
 1 mos. given 1 dose of
35. Children 0-59 mos. seen - Total
100,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos seen - Total 0 0 0 36. Stunted - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos. old given 2
37. Wasted - Total
tamin A 200,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
1 months old who completed
38. Overweight/Obese - Total
lementation - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS

2-23 mos. seen - Total 39. Normal - Total

0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col. 1) (Col 2) (Col 3)

y/o dewormed (2 doses) - 43. Adolescents, 10-19 y/o dewormed

0 0 0 (2 doses) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

ren 12-59 mos. old 50. Diarrhea cases 0-59 mos. received
itamin A - Total 0 0 0 ORS w/ zinc - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old seen 51. Pneumonia cases 0-59 mos. old
0 0 0 seen - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old 52. Pneumonia cases 0-59 mos. old
ORS - Total 0 0 0 completed treatment - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
 To be submitted Quarterly
ous Disease Prevention and Control Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
miasis Prevention and Control E2. Schistosomiasis Prevention and Control (Con't.)
le 5-65 y/o who ingested 7. No. confirmed chronic cases - Total
- Total 0
nts seen - Total 0 8. No. of confirmed cases (acute and
ected cases seen 0 chronic) - Total
clinically diagnosed cases - 9. No. of cases treated - Total
0
rmed acute cases - Total 0 10. No. of confirmed chronic cases
nic clinically diagnosed referred to a hospital facility - Total
al 0
_________________________________________
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
M1
RGY
Total

(Col. 3)

New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
 0 0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0 0
0
0
0 0
0
0
0 0
0
0
 0 0
0
0

Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
 Total
(Col 4)

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Total
(Col 4)
0
0
0
0
0
0

0
0
0
 0
0
0
0
0
0

0
0
0

0
0
0

0
0
0
Total
(Col 4)

0
0
0

0
0
0

0
0
0

0
0
0
 Total
(Col 4)
't.)

Total
(Col 4)
 FHSIS REPORT for the MONTH: ___JANUARY_____
Name of Barangay: _____TAGPAKO_________
Name of BHS: _______________________
Name of Municipality/City: _______________________
Name of Province: ________________________
Projected Population of the Year: _______________________
For submission to RHU/MHC

Section A. Family Planning Services and Dewor

A1. Modern FP Unmet Need Age Total

(Col. 1) (Col. 2) (Col. 3)

10-14 15-19 20-49
1. No. of WRA with unmet
need for modern FP - Total 5 5 5
15
• NHTS 5 5 5 15
• Non-NHTS 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
a. Female Sterilization/ BTL - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
b. Male Sterilization/ NSV-Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
c. Condom - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d. Pills - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
 d.1 Pills-POP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d.2 Pills-COC - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
e. Injectables (DMPA/ POI) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
f. Implant - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g. IUD (IUD-I and IUD-PP) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.1 IUD-I- Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.2 IUD-PP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
h. NFP-LAM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
i. NFP-BBT - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
j. NFP-CMM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
k. NFP-STM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
l. NFP-SDM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
m. Total Current Users 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
Section B. Maternal Care
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
1. No. of pregnant women w/
at least 4 prenatal check-
ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
2. No. of pregnant women
assessed of their nutritional
status during the 1st tri. -Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
c. No. of pregnant women
seen in the first trimester
who have high BMI - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
3. No. of pregnant women for
the first time given 2 doses of
Td vaccination - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
4. No. of pregnant women for
the 2nd or more times given
at least 3 doses of Td
vaccination (Td2 Plus) - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
5. No. of pregnant women who
completed the dose of iron
with folic acid
supplementation - Total 0 0 0 0
 • NHTS 0
• Non-NHTS 0
6. No. of pregnant women who
completed doses of calcium
carbonate supplementation -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
12. No. of pregnant women
tested positive for Hepatitis
B - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
13. No. of pregnant women
screened for HIV - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
14. No. of pregnant women
tested for CBC or Hgb&Hct
count - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
15. No. of pregnant women
tested for CBC or Hgb&Hct
count diagnosed with
anemia - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
16. No. of pregnant women
screened for gestational
diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
17.   No. of pregnant women
tested positive for
gestational diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col 3)  (Col. 4)
 Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
a. No. of deliveries attended
by a doctor - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by a nurse – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
c. No. of deliveries attended
by midwives - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
22. No. of deliveries attended by
non-skilled health
professionals - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
a. No. of deliveries attended
by Hilot/TBA - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by others - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
23. No. of health facility-based
deliveries - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
27c. No. of fetal deaths - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
27d. No. of abortion/
miscarriage - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0

Section C. Child Care a

Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
C1. Immunization Services
1. CPAB - Total 0 0 0 6. DPT-HiB-HepB 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
2. BCG - Total 0 0 0 7. OPV 1 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
3. HepB, within 24 hours. - Total 0 0 0 8. OPV 2 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
4. DPT-HiB-HepB 1 - Total 0 0 0 9. OPV 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
5. DPT-HiB-HepB 2 - Total 0 0 0 10. IPV - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
16. FIC - Total 0 0 0 18. Td, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
17. CIC - Total 0 0 0 19. MR, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
C2. Nutrition Services
22. Newborns initiated on breastfeeding
immediately after birth lasting to 90 mins - 28. Infants 6-11 mos. old seen - Total
Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
23. Preterm/LBW infants given iron 29. Infants 6-11 mos. given 1 dose of
supplementation - Total 0 0 0 Vitamin A 100,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
24. Infants 6 mos. old seen - Total 0 0 0 30. Children 12-59 mos seen - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
25. Infants exclusively breastfed until 6th month - 31. Children 12-59 mos. old given 2
Total 0 0 0 doses of Vitamin A 200,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
26. Infants 6 mos. old initiated to complementary 32. Infant 6-11 months old who completed
feeding with continued breastfeeding - Total 0 0 0 MNP supplementation - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
27. Infants 6 mos. old initiated to complementary
feeding but no longer or never been breastfed 33. Children 12-23 mos. seen - Total
- Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
0
40. 1-19 y/o given 2 doses of deworming drug - 42. SAC, 5-9 y/o dewormed (2 doses) -
Total 0 0 0 Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
41. PSAC, 1-4 y/o dewormed (2 doses) - Total 0 0 0
• NHTS 0
• Non-NHTS 0
0
44. Sick Infants 6-11 mos. old seen - Total 47. Sick Children 12-59 mos. old
0 0 0 received Vitamin A - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
45. Sick Infants 6-11 mos. old received 48. Diarrhea cases 0-59 months old seen
Vitamin A - Total 0 0 0 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
49. Diarrhea cases 0-59 months old
46. Sick Children 12-59 mos. old seen - Total
0 0 0 received ORS - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
 To be submitted Qua
Section E. Infectious Disease Preven
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
E1. Filariasis Prevention and Control E2. Schistosomiasis Prevention and Contro
1. No. of individual examined for lymphatic 1. No. of people 5-65 y/o who ingested
filariasis - Total 0 MDA drugs - Total
2. No. of individual examined found positive for 2. No. of patients seen - Total
lymphatic filariasis - Total 0 3. No. of suspected cases seen
3. No. of lymphatic filariasis cases examined with 4. No. acute clinically diagnosed cases -
manifestation of either lymphedema,hydrocele, Total
elephantiasis - Total
0 5. No. of confirmed acute cases - Total
6. No. of chronic clinically diagnosed
cases - Total
Section F. _________________________
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
 ___JANUARY_____ YEAR: ____2020___

M1
AGPAKO__________________________
_________________________
_________________________

BRGY
________________________
________________________
r submission to RHU/MHC

Services and Deworming for Women of Reproductive Age

Total A3. Deworming Services SES Total

Col. 3) (Col. 1) (Col. 2) (Col. 3)

NHTS Non-NHTS
1. No. of women 20-49 years old given 2 doses of
15 deworming drugs - Total
0 0 0
15
0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
on B. Maternal Care and Services
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

a. Number of pregnant women seen in the

first trimester who have normal BMI -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of pregnant women seen in the first
trimester who have low BMI - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

7. No. of pregnant women given iodine

capsules – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
8. No. of pregnant women given one dose
of deworming tablet - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
9. No. of pregnant women screened for
syphilis - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
10. No. of pregnant women tested positive
for syphilis - Total

0 0 0 0
 • NHTS 0
• Non-NHTS 0
11. No. of pregnant women screened for
Hepatitis B - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
18. No. of deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
19. No. of live births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20a. No. of live births with normal birth
weight - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20b. No. of live births with low birth weight
- Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
20c. No. of live births with unknown birth
weight- Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
21. No. of deliveries attended by skilled
health professionals - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col 3)  (Col. 4)
rks Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

24a. No. of deliveries in public health

facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
24b. No. of deliveries in private health
facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
25. No. of non-facility-based deliveries -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
26a. No. of vaginal deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
26b. No. of deliveries by cesarean
section – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
27a. No. of full-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
27b. No. of pre-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B3. Postpartum and Newborn Care
28. No. of postpartum women together
with their newborn who completed at
least 2 postpartum check-ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
 29. No. of postpartum women who
completed iron with folic acid
supplementation - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
30. No. of postpartum women with
Vitamin A supplementation – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
ction C. Child Care and Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)

epB 3 - Total 0 0 0 11. PCV 1 - Total 0 0

0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 12. PCV 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 13. PCV 3 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 14. MMR 1 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
0 0 0 15. MMR 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
1 (November) - Total 0 0 0 20. Td, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
e 1 (November) - Total 0 0 0 21. MR, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

34. Children 12-23 mos. who completed

1 mos. old seen - Total
MNP supplementation - Total
0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
 1 mos. given 1 dose of
35. Children 0-59 mos. seen - Total
100,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos seen - Total 0 0 0 36. Stunted - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos. old given 2
37. Wasted - Total
tamin A 200,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
1 months old who completed
38. Overweight/Obese - Total
lementation - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS

2-23 mos. seen - Total 39. Normal - Total

0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col. 1) (Col 2) (Col 3)

y/o dewormed (2 doses) - 43. Adolescents, 10-19 y/o dewormed

0 0 0 (2 doses) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

ren 12-59 mos. old 50. Diarrhea cases 0-59 mos. received
itamin A - Total 0 0 0 ORS w/ zinc - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old seen 51. Pneumonia cases 0-59 mos. old
0 0 0 seen - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old 52. Pneumonia cases 0-59 mos. old
ORS - Total 0 0 0 completed treatment - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
 To be submitted Quarterly
ous Disease Prevention and Control Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
miasis Prevention and Control E2. Schistosomiasis Prevention and Control (Con't.)
le 5-65 y/o who ingested 7. No. confirmed chronic cases - Total
- Total 0
nts seen - Total 0 8. No. of confirmed cases (acute and
ected cases seen 0 chronic) - Total
clinically diagnosed cases - 9. No. of cases treated - Total
0
rmed acute cases - Total 0 10. No. of confirmed chronic cases
nic clinically diagnosed referred to a hospital facility - Total
al 0
_________________________________________
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
M1
RGY
Total

(Col. 3)

New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
 0 0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0 0
0
0
0 0
0
0
0 0
0
0
 0 0
0
0

Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
 Total
(Col 4)

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Total
(Col 4)
0
0
0
0
0
0

0
0
0
 0
0
0
0
0
0

0
0
0

0
0
0

0
0
0
Total
(Col 4)

0
0
0

0
0
0

0
0
0

0
0
0
 Total
(Col 4)
't.)

Total
(Col 4)
 FHSIS REPORT for the MONTH: ___JANUARY_____
Name of Barangay: _____TAGPAKO_________
Name of BHS: _______________________
Name of Municipality/City: _______________________
Name of Province: ________________________
Projected Population of the Year: _______________________
For submission to RHU/MHC

Section A. Family Planning Services and Dewor

A1. Modern FP Unmet Need Age Total

(Col. 1) (Col. 2) (Col. 3)

10-14 15-19 20-49
1. No. of WRA with unmet
need for modern FP - Total 5 5 5
15
• NHTS 5 5 5 15
• Non-NHTS 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
a. Female Sterilization/ BTL - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
b. Male Sterilization/ NSV-Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
c. Condom - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d. Pills - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
 d.1 Pills-POP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d.2 Pills-COC - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
e. Injectables (DMPA/ POI) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
f. Implant - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g. IUD (IUD-I and IUD-PP) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.1 IUD-I- Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.2 IUD-PP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
h. NFP-LAM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
i. NFP-BBT - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
j. NFP-CMM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
k. NFP-STM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
l. NFP-SDM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
m. Total Current Users 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
Section B. Maternal Care
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
1. No. of pregnant women w/
at least 4 prenatal check-
ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
2. No. of pregnant women
assessed of their nutritional
status during the 1st tri. -Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
c. No. of pregnant women
seen in the first trimester
who have high BMI - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
3. No. of pregnant women for
the first time given 2 doses of
Td vaccination - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
4. No. of pregnant women for
the 2nd or more times given
at least 3 doses of Td
vaccination (Td2 Plus) - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
5. No. of pregnant women who
completed the dose of iron
with folic acid
supplementation - Total 0 0 0 0
 • NHTS 0
• Non-NHTS 0
6. No. of pregnant women who
completed doses of calcium
carbonate supplementation -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
12. No. of pregnant women
tested positive for Hepatitis
B - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
13. No. of pregnant women
screened for HIV - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
14. No. of pregnant women
tested for CBC or Hgb&Hct
count - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
15. No. of pregnant women
tested for CBC or Hgb&Hct
count diagnosed with
anemia - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
16. No. of pregnant women
screened for gestational
diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
17.   No. of pregnant women
tested positive for
gestational diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col 3)  (Col. 4)
 Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
a. No. of deliveries attended
by a doctor - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by a nurse – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
c. No. of deliveries attended
by midwives - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
22. No. of deliveries attended by
non-skilled health
professionals - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
a. No. of deliveries attended
by Hilot/TBA - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by others - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
23. No. of health facility-based
deliveries - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
27c. No. of fetal deaths - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
27d. No. of abortion/
miscarriage - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0

Section C. Child Care a

Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
C1. Immunization Services
1. CPAB - Total 0 0 0 6. DPT-HiB-HepB 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
2. BCG - Total 0 0 0 7. OPV 1 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
3. HepB, within 24 hours. - Total 0 0 0 8. OPV 2 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
4. DPT-HiB-HepB 1 - Total 0 0 0 9. OPV 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
5. DPT-HiB-HepB 2 - Total 0 0 0 10. IPV - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
16. FIC - Total 0 0 0 18. Td, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
17. CIC - Total 0 0 0 19. MR, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
C2. Nutrition Services
22. Newborns initiated on breastfeeding
immediately after birth lasting to 90 mins - 28. Infants 6-11 mos. old seen - Total
Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
23. Preterm/LBW infants given iron 29. Infants 6-11 mos. given 1 dose of
supplementation - Total 0 0 0 Vitamin A 100,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
24. Infants 6 mos. old seen - Total 0 0 0 30. Children 12-59 mos seen - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
25. Infants exclusively breastfed until 6th month - 31. Children 12-59 mos. old given 2
Total 0 0 0 doses of Vitamin A 200,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
26. Infants 6 mos. old initiated to complementary 32. Infant 6-11 months old who completed
feeding with continued breastfeeding - Total 0 0 0 MNP supplementation - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
27. Infants 6 mos. old initiated to complementary
feeding but no longer or never been breastfed 33. Children 12-23 mos. seen - Total
- Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
0
40. 1-19 y/o given 2 doses of deworming drug - 42. SAC, 5-9 y/o dewormed (2 doses) -
Total 0 0 0 Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
41. PSAC, 1-4 y/o dewormed (2 doses) - Total 0 0 0
• NHTS 0
• Non-NHTS 0
0
44. Sick Infants 6-11 mos. old seen - Total 47. Sick Children 12-59 mos. old
0 0 0 received Vitamin A - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
45. Sick Infants 6-11 mos. old received 48. Diarrhea cases 0-59 months old seen
Vitamin A - Total 0 0 0 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
49. Diarrhea cases 0-59 months old
46. Sick Children 12-59 mos. old seen - Total
0 0 0 received ORS - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
 To be submitted Qua
Section E. Infectious Disease Preven
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
E1. Filariasis Prevention and Control E2. Schistosomiasis Prevention and Contro
1. No. of individual examined for lymphatic 1. No. of people 5-65 y/o who ingested
filariasis - Total 0 MDA drugs - Total
2. No. of individual examined found positive for 2. No. of patients seen - Total
lymphatic filariasis - Total 0 3. No. of suspected cases seen
3. No. of lymphatic filariasis cases examined with 4. No. acute clinically diagnosed cases -
manifestation of either lymphedema,hydrocele, Total
elephantiasis - Total
0 5. No. of confirmed acute cases - Total
6. No. of chronic clinically diagnosed
cases - Total
Section F. _________________________
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
 ___JANUARY_____ YEAR: ____2020___

M1
AGPAKO__________________________
_________________________
_________________________

BRGY
________________________
________________________
r submission to RHU/MHC

Services and Deworming for Women of Reproductive Age

Total A3. Deworming Services SES Total

Col. 3) (Col. 1) (Col. 2) (Col. 3)

NHTS Non-NHTS
1. No. of women 20-49 years old given 2 doses of
15 deworming drugs - Total
0 0 0
15
0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
on B. Maternal Care and Services
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

a. Number of pregnant women seen in the

first trimester who have normal BMI -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of pregnant women seen in the first
trimester who have low BMI - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

7. No. of pregnant women given iodine

capsules – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
8. No. of pregnant women given one dose
of deworming tablet - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
9. No. of pregnant women screened for
syphilis - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
10. No. of pregnant women tested positive
for syphilis - Total

0 0 0 0
 • NHTS 0
• Non-NHTS 0
11. No. of pregnant women screened for
Hepatitis B - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
18. No. of deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
19. No. of live births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20a. No. of live births with normal birth
weight - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20b. No. of live births with low birth weight
- Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
20c. No. of live births with unknown birth
weight- Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
21. No. of deliveries attended by skilled
health professionals - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col 3)  (Col. 4)
rks Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

24a. No. of deliveries in public health

facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
24b. No. of deliveries in private health
facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
25. No. of non-facility-based deliveries -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
26a. No. of vaginal deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
26b. No. of deliveries by cesarean
section – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
27a. No. of full-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
27b. No. of pre-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B3. Postpartum and Newborn Care
28. No. of postpartum women together
with their newborn who completed at
least 2 postpartum check-ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
 29. No. of postpartum women who
completed iron with folic acid
supplementation - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
30. No. of postpartum women with
Vitamin A supplementation – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
ction C. Child Care and Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)

epB 3 - Total 0 0 0 11. PCV 1 - Total 0 0

0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 12. PCV 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 13. PCV 3 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 14. MMR 1 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
0 0 0 15. MMR 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
1 (November) - Total 0 0 0 20. Td, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
e 1 (November) - Total 0 0 0 21. MR, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

34. Children 12-23 mos. who completed

1 mos. old seen - Total
MNP supplementation - Total
0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
 1 mos. given 1 dose of
35. Children 0-59 mos. seen - Total
100,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos seen - Total 0 0 0 36. Stunted - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos. old given 2
37. Wasted - Total
tamin A 200,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
1 months old who completed
38. Overweight/Obese - Total
lementation - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS

2-23 mos. seen - Total 39. Normal - Total

0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col. 1) (Col 2) (Col 3)

y/o dewormed (2 doses) - 43. Adolescents, 10-19 y/o dewormed

0 0 0 (2 doses) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

ren 12-59 mos. old 50. Diarrhea cases 0-59 mos. received
itamin A - Total 0 0 0 ORS w/ zinc - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old seen 51. Pneumonia cases 0-59 mos. old
0 0 0 seen - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old 52. Pneumonia cases 0-59 mos. old
ORS - Total 0 0 0 completed treatment - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
 To be submitted Quarterly
ous Disease Prevention and Control Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
miasis Prevention and Control E2. Schistosomiasis Prevention and Control (Con't.)
le 5-65 y/o who ingested 7. No. confirmed chronic cases - Total
- Total 0
nts seen - Total 0 8. No. of confirmed cases (acute and
ected cases seen 0 chronic) - Total
clinically diagnosed cases - 9. No. of cases treated - Total
0
rmed acute cases - Total 0 10. No. of confirmed chronic cases
nic clinically diagnosed referred to a hospital facility - Total
al 0
_________________________________________
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
M1
RGY
Total

(Col. 3)

New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
 0 0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0 0
0
0
0 0
0
0
0 0
0
0
 0 0
0
0

Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
 Total
(Col 4)

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Total
(Col 4)
0
0
0
0
0
0

0
0
0
 0
0
0
0
0
0

0
0
0

0
0
0

0
0
0
Total
(Col 4)

0
0
0

0
0
0

0
0
0

0
0
0
 Total
(Col 4)
't.)

Total
(Col 4)
 FHSIS REPORT for the MONTH: ___JANUARY_____
Name of Barangay: _____TAGPAKO_________
Name of BHS: _______________________
Name of Municipality/City: _______________________
Name of Province: ________________________
Projected Population of the Year: _______________________
For submission to RHU/MHC

Section A. Family Planning Services and Dewor

A1. Modern FP Unmet Need Age Total

(Col. 1) (Col. 2) (Col. 3)

10-14 15-19 20-49
1. No. of WRA with unmet
need for modern FP - Total 5 5 5
15
• NHTS 5 5 5 15
• Non-NHTS 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
a. Female Sterilization/ BTL - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
b. Male Sterilization/ NSV-Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
c. Condom - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d. Pills - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
 d.1 Pills-POP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d.2 Pills-COC - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
e. Injectables (DMPA/ POI) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
f. Implant - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g. IUD (IUD-I and IUD-PP) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.1 IUD-I- Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.2 IUD-PP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
h. NFP-LAM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
i. NFP-BBT - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
j. NFP-CMM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
k. NFP-STM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
l. NFP-SDM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
m. Total Current Users 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
Section B. Maternal Care
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
1. No. of pregnant women w/
at least 4 prenatal check-
ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
2. No. of pregnant women
assessed of their nutritional
status during the 1st tri. -Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
c. No. of pregnant women
seen in the first trimester
who have high BMI - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
3. No. of pregnant women for
the first time given 2 doses of
Td vaccination - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
4. No. of pregnant women for
the 2nd or more times given
at least 3 doses of Td
vaccination (Td2 Plus) - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
5. No. of pregnant women who
completed the dose of iron
with folic acid
supplementation - Total 0 0 0 0
 • NHTS 0
• Non-NHTS 0
6. No. of pregnant women who
completed doses of calcium
carbonate supplementation -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
12. No. of pregnant women
tested positive for Hepatitis
B - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
13. No. of pregnant women
screened for HIV - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
14. No. of pregnant women
tested for CBC or Hgb&Hct
count - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
15. No. of pregnant women
tested for CBC or Hgb&Hct
count diagnosed with
anemia - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
16. No. of pregnant women
screened for gestational
diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
17.   No. of pregnant women
tested positive for
gestational diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col 3)  (Col. 4)
 Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
a. No. of deliveries attended
by a doctor - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by a nurse – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
c. No. of deliveries attended
by midwives - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
22. No. of deliveries attended by
non-skilled health
professionals - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
a. No. of deliveries attended
by Hilot/TBA - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by others - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
23. No. of health facility-based
deliveries - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
27c. No. of fetal deaths - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
27d. No. of abortion/
miscarriage - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0

Section C. Child Care a

Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
C1. Immunization Services
1. CPAB - Total 0 0 0 6. DPT-HiB-HepB 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
2. BCG - Total 0 0 0 7. OPV 1 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
3. HepB, within 24 hours. - Total 0 0 0 8. OPV 2 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
4. DPT-HiB-HepB 1 - Total 0 0 0 9. OPV 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
5. DPT-HiB-HepB 2 - Total 0 0 0 10. IPV - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
16. FIC - Total 0 0 0 18. Td, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
17. CIC - Total 0 0 0 19. MR, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
C2. Nutrition Services
22. Newborns initiated on breastfeeding
immediately after birth lasting to 90 mins - 28. Infants 6-11 mos. old seen - Total
Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
23. Preterm/LBW infants given iron 29. Infants 6-11 mos. given 1 dose of
supplementation - Total 0 0 0 Vitamin A 100,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
24. Infants 6 mos. old seen - Total 0 0 0 30. Children 12-59 mos seen - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
25. Infants exclusively breastfed until 6th month - 31. Children 12-59 mos. old given 2
Total 0 0 0 doses of Vitamin A 200,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
26. Infants 6 mos. old initiated to complementary 32. Infant 6-11 months old who completed
feeding with continued breastfeeding - Total 0 0 0 MNP supplementation - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
27. Infants 6 mos. old initiated to complementary
feeding but no longer or never been breastfed 33. Children 12-23 mos. seen - Total
- Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
0
40. 1-19 y/o given 2 doses of deworming drug - 42. SAC, 5-9 y/o dewormed (2 doses) -
Total 0 0 0 Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
41. PSAC, 1-4 y/o dewormed (2 doses) - Total 0 0 0
• NHTS 0
• Non-NHTS 0
0
44. Sick Infants 6-11 mos. old seen - Total 47. Sick Children 12-59 mos. old
0 0 0 received Vitamin A - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
45. Sick Infants 6-11 mos. old received 48. Diarrhea cases 0-59 months old seen
Vitamin A - Total 0 0 0 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
49. Diarrhea cases 0-59 months old
46. Sick Children 12-59 mos. old seen - Total
0 0 0 received ORS - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
 To be submitted Qua
Section E. Infectious Disease Preven
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
E1. Filariasis Prevention and Control E2. Schistosomiasis Prevention and Contro
1. No. of individual examined for lymphatic 1. No. of people 5-65 y/o who ingested
filariasis - Total 0 MDA drugs - Total
2. No. of individual examined found positive for 2. No. of patients seen - Total
lymphatic filariasis - Total 0 3. No. of suspected cases seen
3. No. of lymphatic filariasis cases examined with 4. No. acute clinically diagnosed cases -
manifestation of either lymphedema,hydrocele, Total
elephantiasis - Total
0 5. No. of confirmed acute cases - Total
6. No. of chronic clinically diagnosed
cases - Total
Section F. _________________________
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
 ___JANUARY_____ YEAR: ____2020___

M1
AGPAKO__________________________
_________________________
_________________________

BRGY
________________________
________________________
r submission to RHU/MHC

Services and Deworming for Women of Reproductive Age

Total A3. Deworming Services SES Total

Col. 3) (Col. 1) (Col. 2) (Col. 3)

NHTS Non-NHTS
1. No. of women 20-49 years old given 2 doses of
15 deworming drugs - Total
0 0 0
15
0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
on B. Maternal Care and Services
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

a. Number of pregnant women seen in the

first trimester who have normal BMI -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of pregnant women seen in the first
trimester who have low BMI - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

7. No. of pregnant women given iodine

capsules – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
8. No. of pregnant women given one dose
of deworming tablet - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
9. No. of pregnant women screened for
syphilis - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
10. No. of pregnant women tested positive
for syphilis - Total

0 0 0 0
 • NHTS 0
• Non-NHTS 0
11. No. of pregnant women screened for
Hepatitis B - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
18. No. of deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
19. No. of live births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20a. No. of live births with normal birth
weight - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20b. No. of live births with low birth weight
- Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
20c. No. of live births with unknown birth
weight- Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
21. No. of deliveries attended by skilled
health professionals - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col 3)  (Col. 4)
rks Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

24a. No. of deliveries in public health

facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
24b. No. of deliveries in private health
facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
25. No. of non-facility-based deliveries -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
26a. No. of vaginal deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
26b. No. of deliveries by cesarean
section – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
27a. No. of full-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
27b. No. of pre-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B3. Postpartum and Newborn Care
28. No. of postpartum women together
with their newborn who completed at
least 2 postpartum check-ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
 29. No. of postpartum women who
completed iron with folic acid
supplementation - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
30. No. of postpartum women with
Vitamin A supplementation – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
ction C. Child Care and Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)

epB 3 - Total 0 0 0 11. PCV 1 - Total 0 0

0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 12. PCV 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 13. PCV 3 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 14. MMR 1 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
0 0 0 15. MMR 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
1 (November) - Total 0 0 0 20. Td, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
e 1 (November) - Total 0 0 0 21. MR, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

34. Children 12-23 mos. who completed

1 mos. old seen - Total
MNP supplementation - Total
0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
 1 mos. given 1 dose of
35. Children 0-59 mos. seen - Total
100,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos seen - Total 0 0 0 36. Stunted - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos. old given 2
37. Wasted - Total
tamin A 200,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
1 months old who completed
38. Overweight/Obese - Total
lementation - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS

2-23 mos. seen - Total 39. Normal - Total

0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col. 1) (Col 2) (Col 3)

y/o dewormed (2 doses) - 43. Adolescents, 10-19 y/o dewormed

0 0 0 (2 doses) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

ren 12-59 mos. old 50. Diarrhea cases 0-59 mos. received
itamin A - Total 0 0 0 ORS w/ zinc - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old seen 51. Pneumonia cases 0-59 mos. old
0 0 0 seen - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old 52. Pneumonia cases 0-59 mos. old
ORS - Total 0 0 0 completed treatment - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
 To be submitted Quarterly
ous Disease Prevention and Control Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
miasis Prevention and Control E2. Schistosomiasis Prevention and Control (Con't.)
le 5-65 y/o who ingested 7. No. confirmed chronic cases - Total
- Total 0
nts seen - Total 0 8. No. of confirmed cases (acute and
ected cases seen 0 chronic) - Total
clinically diagnosed cases - 9. No. of cases treated - Total
0
rmed acute cases - Total 0 10. No. of confirmed chronic cases
nic clinically diagnosed referred to a hospital facility - Total
al 0
_________________________________________
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
M1
RGY
Total

(Col. 3)

New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
 0 0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0 0
0
0
0 0
0
0
0 0
0
0
 0 0
0
0

Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
 Total
(Col 4)

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Total
(Col 4)
0
0
0
0
0
0

0
0
0
 0
0
0
0
0
0

0
0
0

0
0
0

0
0
0
Total
(Col 4)

0
0
0

0
0
0

0
0
0

0
0
0
 Total
(Col 4)
't.)

Total
(Col 4)
 FHSIS REPORT for the MONTH: ___JANUARY_____
Name of Barangay: _____TAGPAKO_________
Name of BHS: _______________________
Name of Municipality/City: _______________________
Name of Province: ________________________
Projected Population of the Year: _______________________
For submission to RHU/MHC

Section A. Family Planning Services and Dewor

A1. Modern FP Unmet Need Age Total

(Col. 1) (Col. 2) (Col. 3)

10-14 15-19 20-49
1. No. of WRA with unmet
need for modern FP - Total 5 5 5
15
• NHTS 5 5 5 15
• Non-NHTS 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
a. Female Sterilization/ BTL - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
b. Male Sterilization/ NSV-Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
c. Condom - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d. Pills - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
 d.1 Pills-POP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d.2 Pills-COC - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
e. Injectables (DMPA/ POI) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
f. Implant - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g. IUD (IUD-I and IUD-PP) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.1 IUD-I- Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.2 IUD-PP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
h. NFP-LAM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
i. NFP-BBT - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
j. NFP-CMM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
k. NFP-STM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
l. NFP-SDM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
m. Total Current Users 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
Section B. Maternal Care
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
1. No. of pregnant women w/
at least 4 prenatal check-
ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
2. No. of pregnant women
assessed of their nutritional
status during the 1st tri. -Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
c. No. of pregnant women
seen in the first trimester
who have high BMI - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
3. No. of pregnant women for
the first time given 2 doses of
Td vaccination - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
4. No. of pregnant women for
the 2nd or more times given
at least 3 doses of Td
vaccination (Td2 Plus) - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
5. No. of pregnant women who
completed the dose of iron
with folic acid
supplementation - Total 0 0 0 0
 • NHTS 0
• Non-NHTS 0
6. No. of pregnant women who
completed doses of calcium
carbonate supplementation -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
12. No. of pregnant women
tested positive for Hepatitis
B - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
13. No. of pregnant women
screened for HIV - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
14. No. of pregnant women
tested for CBC or Hgb&Hct
count - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
15. No. of pregnant women
tested for CBC or Hgb&Hct
count diagnosed with
anemia - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
16. No. of pregnant women
screened for gestational
diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
17.   No. of pregnant women
tested positive for
gestational diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col 3)  (Col. 4)
 Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
a. No. of deliveries attended
by a doctor - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by a nurse – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
c. No. of deliveries attended
by midwives - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
22. No. of deliveries attended by
non-skilled health
professionals - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
a. No. of deliveries attended
by Hilot/TBA - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by others - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
23. No. of health facility-based
deliveries - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
27c. No. of fetal deaths - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
27d. No. of abortion/
miscarriage - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0

Section C. Child Care a

Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
C1. Immunization Services
1. CPAB - Total 0 0 0 6. DPT-HiB-HepB 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
2. BCG - Total 0 0 0 7. OPV 1 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
3. HepB, within 24 hours. - Total 0 0 0 8. OPV 2 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
4. DPT-HiB-HepB 1 - Total 0 0 0 9. OPV 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
5. DPT-HiB-HepB 2 - Total 0 0 0 10. IPV - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
16. FIC - Total 0 0 0 18. Td, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
17. CIC - Total 0 0 0 19. MR, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
C2. Nutrition Services
22. Newborns initiated on breastfeeding
immediately after birth lasting to 90 mins - 28. Infants 6-11 mos. old seen - Total
Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
23. Preterm/LBW infants given iron 29. Infants 6-11 mos. given 1 dose of
supplementation - Total 0 0 0 Vitamin A 100,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
24. Infants 6 mos. old seen - Total 0 0 0 30. Children 12-59 mos seen - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
25. Infants exclusively breastfed until 6th month - 31. Children 12-59 mos. old given 2
Total 0 0 0 doses of Vitamin A 200,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
26. Infants 6 mos. old initiated to complementary 32. Infant 6-11 months old who completed
feeding with continued breastfeeding - Total 0 0 0 MNP supplementation - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
27. Infants 6 mos. old initiated to complementary
feeding but no longer or never been breastfed 33. Children 12-23 mos. seen - Total
- Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
0
40. 1-19 y/o given 2 doses of deworming drug - 42. SAC, 5-9 y/o dewormed (2 doses) -
Total 0 0 0 Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
41. PSAC, 1-4 y/o dewormed (2 doses) - Total 0 0 0
• NHTS 0
• Non-NHTS 0
0
44. Sick Infants 6-11 mos. old seen - Total 47. Sick Children 12-59 mos. old
0 0 0 received Vitamin A - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
45. Sick Infants 6-11 mos. old received 48. Diarrhea cases 0-59 months old seen
Vitamin A - Total 0 0 0 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
49. Diarrhea cases 0-59 months old
46. Sick Children 12-59 mos. old seen - Total
0 0 0 received ORS - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
 To be submitted Qua
Section E. Infectious Disease Preven
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
E1. Filariasis Prevention and Control E2. Schistosomiasis Prevention and Contro
1. No. of individual examined for lymphatic 1. No. of people 5-65 y/o who ingested
filariasis - Total 0 MDA drugs - Total
2. No. of individual examined found positive for 2. No. of patients seen - Total
lymphatic filariasis - Total 0 3. No. of suspected cases seen
3. No. of lymphatic filariasis cases examined with 4. No. acute clinically diagnosed cases -
manifestation of either lymphedema,hydrocele, Total
elephantiasis - Total
0 5. No. of confirmed acute cases - Total
6. No. of chronic clinically diagnosed
cases - Total
Section F. _________________________
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
 ___JANUARY_____ YEAR: ____2020___

M1
AGPAKO__________________________
_________________________
_________________________

BRGY
________________________
________________________
r submission to RHU/MHC

Services and Deworming for Women of Reproductive Age

Total A3. Deworming Services SES Total

Col. 3) (Col. 1) (Col. 2) (Col. 3)

NHTS Non-NHTS
1. No. of women 20-49 years old given 2 doses of
15 deworming drugs - Total
0 0 0
15
0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
on B. Maternal Care and Services
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

a. Number of pregnant women seen in the

first trimester who have normal BMI -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of pregnant women seen in the first
trimester who have low BMI - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

7. No. of pregnant women given iodine

capsules – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
8. No. of pregnant women given one dose
of deworming tablet - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
9. No. of pregnant women screened for
syphilis - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
10. No. of pregnant women tested positive
for syphilis - Total

0 0 0 0
 • NHTS 0
• Non-NHTS 0
11. No. of pregnant women screened for
Hepatitis B - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
18. No. of deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
19. No. of live births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20a. No. of live births with normal birth
weight - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20b. No. of live births with low birth weight
- Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
20c. No. of live births with unknown birth
weight- Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
21. No. of deliveries attended by skilled
health professionals - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col 3)  (Col. 4)
rks Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

24a. No. of deliveries in public health

facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
24b. No. of deliveries in private health
facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
25. No. of non-facility-based deliveries -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
26a. No. of vaginal deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
26b. No. of deliveries by cesarean
section – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
27a. No. of full-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
27b. No. of pre-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B3. Postpartum and Newborn Care
28. No. of postpartum women together
with their newborn who completed at
least 2 postpartum check-ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
 29. No. of postpartum women who
completed iron with folic acid
supplementation - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
30. No. of postpartum women with
Vitamin A supplementation – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
ction C. Child Care and Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)

epB 3 - Total 0 0 0 11. PCV 1 - Total 0 0

0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 12. PCV 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 13. PCV 3 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 14. MMR 1 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
0 0 0 15. MMR 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
1 (November) - Total 0 0 0 20. Td, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
e 1 (November) - Total 0 0 0 21. MR, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

34. Children 12-23 mos. who completed

1 mos. old seen - Total
MNP supplementation - Total
0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
 1 mos. given 1 dose of
35. Children 0-59 mos. seen - Total
100,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos seen - Total 0 0 0 36. Stunted - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos. old given 2
37. Wasted - Total
tamin A 200,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
1 months old who completed
38. Overweight/Obese - Total
lementation - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS

2-23 mos. seen - Total 39. Normal - Total

0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col. 1) (Col 2) (Col 3)

y/o dewormed (2 doses) - 43. Adolescents, 10-19 y/o dewormed

0 0 0 (2 doses) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

ren 12-59 mos. old 50. Diarrhea cases 0-59 mos. received
itamin A - Total 0 0 0 ORS w/ zinc - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old seen 51. Pneumonia cases 0-59 mos. old
0 0 0 seen - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old 52. Pneumonia cases 0-59 mos. old
ORS - Total 0 0 0 completed treatment - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
 To be submitted Quarterly
ous Disease Prevention and Control Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
miasis Prevention and Control E2. Schistosomiasis Prevention and Control (Con't.)
le 5-65 y/o who ingested 7. No. confirmed chronic cases - Total
- Total 0
nts seen - Total 0 8. No. of confirmed cases (acute and
ected cases seen 0 chronic) - Total
clinically diagnosed cases - 9. No. of cases treated - Total
0
rmed acute cases - Total 0 10. No. of confirmed chronic cases
nic clinically diagnosed referred to a hospital facility - Total
al 0
_________________________________________
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
M1
RGY
Total

(Col. 3)

New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
 0 0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0 0
0
0
0 0
0
0
0 0
0
0
 0 0
0
0

Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
 Total
(Col 4)

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Total
(Col 4)
0
0
0
0
0
0

0
0
0
 0
0
0
0
0
0

0
0
0

0
0
0

0
0
0
Total
(Col 4)

0
0
0

0
0
0

0
0
0

0
0
0
 Total
(Col 4)
't.)

Total
(Col 4)
 FHSIS REPORT for the MONTH: ___JANUARY_____
Name of Barangay: _____TAGPAKO_________
Name of BHS: _______________________
Name of Municipality/City: _______________________
Name of Province: ________________________
Projected Population of the Year: _______________________
For submission to RHU/MHC

Section A. Family Planning Services and Dewor

A1. Modern FP Unmet Need Age Total

(Col. 1) (Col. 2) (Col. 3)

10-14 15-19 20-49
1. No. of WRA with unmet
need for modern FP - Total 5 5 5
15
• NHTS 5 5 5 15
• Non-NHTS 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
a. Female Sterilization/ BTL - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
b. Male Sterilization/ NSV-Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
c. Condom - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d. Pills - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
 d.1 Pills-POP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d.2 Pills-COC - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
e. Injectables (DMPA/ POI) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
f. Implant - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g. IUD (IUD-I and IUD-PP) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.1 IUD-I- Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.2 IUD-PP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
h. NFP-LAM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
i. NFP-BBT - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
j. NFP-CMM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
k. NFP-STM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
l. NFP-SDM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
m. Total Current Users 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
Section B. Maternal Care
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
1. No. of pregnant women w/
at least 4 prenatal check-
ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
2. No. of pregnant women
assessed of their nutritional
status during the 1st tri. -Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
c. No. of pregnant women
seen in the first trimester
who have high BMI - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
3. No. of pregnant women for
the first time given 2 doses of
Td vaccination - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
4. No. of pregnant women for
the 2nd or more times given
at least 3 doses of Td
vaccination (Td2 Plus) - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
5. No. of pregnant women who
completed the dose of iron
with folic acid
supplementation - Total 0 0 0 0
 • NHTS 0
• Non-NHTS 0
6. No. of pregnant women who
completed doses of calcium
carbonate supplementation -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
12. No. of pregnant women
tested positive for Hepatitis
B - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
13. No. of pregnant women
screened for HIV - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
14. No. of pregnant women
tested for CBC or Hgb&Hct
count - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
15. No. of pregnant women
tested for CBC or Hgb&Hct
count diagnosed with
anemia - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
16. No. of pregnant women
screened for gestational
diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
17.   No. of pregnant women
tested positive for
gestational diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col 3)  (Col. 4)
 Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
a. No. of deliveries attended
by a doctor - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by a nurse – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
c. No. of deliveries attended
by midwives - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
22. No. of deliveries attended by
non-skilled health
professionals - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
a. No. of deliveries attended
by Hilot/TBA - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by others - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
23. No. of health facility-based
deliveries - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
27c. No. of fetal deaths - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
27d. No. of abortion/
miscarriage - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0

Section C. Child Care a

Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
C1. Immunization Services
1. CPAB - Total 0 0 0 6. DPT-HiB-HepB 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
2. BCG - Total 0 0 0 7. OPV 1 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
3. HepB, within 24 hours. - Total 0 0 0 8. OPV 2 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
4. DPT-HiB-HepB 1 - Total 0 0 0 9. OPV 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
5. DPT-HiB-HepB 2 - Total 0 0 0 10. IPV - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
16. FIC - Total 0 0 0 18. Td, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
17. CIC - Total 0 0 0 19. MR, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
C2. Nutrition Services
22. Newborns initiated on breastfeeding
immediately after birth lasting to 90 mins - 28. Infants 6-11 mos. old seen - Total
Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
23. Preterm/LBW infants given iron 29. Infants 6-11 mos. given 1 dose of
supplementation - Total 0 0 0 Vitamin A 100,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
24. Infants 6 mos. old seen - Total 0 0 0 30. Children 12-59 mos seen - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
25. Infants exclusively breastfed until 6th month - 31. Children 12-59 mos. old given 2
Total 0 0 0 doses of Vitamin A 200,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
26. Infants 6 mos. old initiated to complementary 32. Infant 6-11 months old who completed
feeding with continued breastfeeding - Total 0 0 0 MNP supplementation - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
27. Infants 6 mos. old initiated to complementary
feeding but no longer or never been breastfed 33. Children 12-23 mos. seen - Total
- Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
0
40. 1-19 y/o given 2 doses of deworming drug - 42. SAC, 5-9 y/o dewormed (2 doses) -
Total 0 0 0 Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
41. PSAC, 1-4 y/o dewormed (2 doses) - Total 0 0 0
• NHTS 0
• Non-NHTS 0
0
44. Sick Infants 6-11 mos. old seen - Total 47. Sick Children 12-59 mos. old
0 0 0 received Vitamin A - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
45. Sick Infants 6-11 mos. old received 48. Diarrhea cases 0-59 months old seen
Vitamin A - Total 0 0 0 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
49. Diarrhea cases 0-59 months old
46. Sick Children 12-59 mos. old seen - Total
0 0 0 received ORS - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
 To be submitted Qua
Section E. Infectious Disease Preven
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
E1. Filariasis Prevention and Control E2. Schistosomiasis Prevention and Contro
1. No. of individual examined for lymphatic 1. No. of people 5-65 y/o who ingested
filariasis - Total 0 MDA drugs - Total
2. No. of individual examined found positive for 2. No. of patients seen - Total
lymphatic filariasis - Total 0 3. No. of suspected cases seen
3. No. of lymphatic filariasis cases examined with 4. No. acute clinically diagnosed cases -
manifestation of either lymphedema,hydrocele, Total
elephantiasis - Total
0 5. No. of confirmed acute cases - Total
6. No. of chronic clinically diagnosed
cases - Total
Section F. _________________________
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
 ___JANUARY_____ YEAR: ____2020___

M1
AGPAKO__________________________
_________________________
_________________________

BRGY
________________________
________________________
r submission to RHU/MHC

Services and Deworming for Women of Reproductive Age

Total A3. Deworming Services SES Total

Col. 3) (Col. 1) (Col. 2) (Col. 3)

NHTS Non-NHTS
1. No. of women 20-49 years old given 2 doses of
15 deworming drugs - Total
0 0 0
15
0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
on B. Maternal Care and Services
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

a. Number of pregnant women seen in the

first trimester who have normal BMI -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of pregnant women seen in the first
trimester who have low BMI - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

7. No. of pregnant women given iodine

capsules – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
8. No. of pregnant women given one dose
of deworming tablet - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
9. No. of pregnant women screened for
syphilis - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
10. No. of pregnant women tested positive
for syphilis - Total

0 0 0 0
 • NHTS 0
• Non-NHTS 0
11. No. of pregnant women screened for
Hepatitis B - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
18. No. of deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
19. No. of live births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20a. No. of live births with normal birth
weight - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20b. No. of live births with low birth weight
- Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
20c. No. of live births with unknown birth
weight- Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
21. No. of deliveries attended by skilled
health professionals - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col 3)  (Col. 4)
rks Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

24a. No. of deliveries in public health

facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
24b. No. of deliveries in private health
facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
25. No. of non-facility-based deliveries -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
26a. No. of vaginal deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
26b. No. of deliveries by cesarean
section – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
27a. No. of full-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
27b. No. of pre-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B3. Postpartum and Newborn Care
28. No. of postpartum women together
with their newborn who completed at
least 2 postpartum check-ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
 29. No. of postpartum women who
completed iron with folic acid
supplementation - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
30. No. of postpartum women with
Vitamin A supplementation – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
ction C. Child Care and Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)

epB 3 - Total 0 0 0 11. PCV 1 - Total 0 0

0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 12. PCV 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 13. PCV 3 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 14. MMR 1 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
0 0 0 15. MMR 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
1 (November) - Total 0 0 0 20. Td, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
e 1 (November) - Total 0 0 0 21. MR, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

34. Children 12-23 mos. who completed

1 mos. old seen - Total
MNP supplementation - Total
0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
 1 mos. given 1 dose of
35. Children 0-59 mos. seen - Total
100,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos seen - Total 0 0 0 36. Stunted - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos. old given 2
37. Wasted - Total
tamin A 200,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
1 months old who completed
38. Overweight/Obese - Total
lementation - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS

2-23 mos. seen - Total 39. Normal - Total

0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col. 1) (Col 2) (Col 3)

y/o dewormed (2 doses) - 43. Adolescents, 10-19 y/o dewormed

0 0 0 (2 doses) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

ren 12-59 mos. old 50. Diarrhea cases 0-59 mos. received
itamin A - Total 0 0 0 ORS w/ zinc - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old seen 51. Pneumonia cases 0-59 mos. old
0 0 0 seen - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old 52. Pneumonia cases 0-59 mos. old
ORS - Total 0 0 0 completed treatment - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
 To be submitted Quarterly
ous Disease Prevention and Control Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
miasis Prevention and Control E2. Schistosomiasis Prevention and Control (Con't.)
le 5-65 y/o who ingested 7. No. confirmed chronic cases - Total
- Total 0
nts seen - Total 0 8. No. of confirmed cases (acute and
ected cases seen 0 chronic) - Total
clinically diagnosed cases - 9. No. of cases treated - Total
0
rmed acute cases - Total 0 10. No. of confirmed chronic cases
nic clinically diagnosed referred to a hospital facility - Total
al 0
_________________________________________
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
M1
RGY
Total

(Col. 3)

New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
 0 0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0 0
0
0
0 0
0
0
0 0
0
0
 0 0
0
0

Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
 Total
(Col 4)

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Total
(Col 4)
0
0
0
0
0
0

0
0
0
 0
0
0
0
0
0

0
0
0

0
0
0

0
0
0
Total
(Col 4)

0
0
0

0
0
0

0
0
0

0
0
0
 Total
(Col 4)
't.)

Total
(Col 4)
 FHSIS REPORT for the MONTH: ___JANUARY_____
Name of Barangay: _____TAGPAKO_________
Name of BHS: _______________________
Name of Municipality/City: _______________________
Name of Province: ________________________
Projected Population of the Year: _______________________
For submission to RHU/MHC

Section A. Family Planning Services and Dewor

A1. Modern FP Unmet Need Age Total

(Col. 1) (Col. 2) (Col. 3)

10-14 15-19 20-49
1. No. of WRA with unmet
need for modern FP - Total 5 5 5
15
• NHTS 5 5 5 15
• Non-NHTS 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
a. Female Sterilization/ BTL - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
b. Male Sterilization/ NSV-Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
c. Condom - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d. Pills - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
 d.1 Pills-POP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d.2 Pills-COC - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
e. Injectables (DMPA/ POI) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
f. Implant - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g. IUD (IUD-I and IUD-PP) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.1 IUD-I- Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.2 IUD-PP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
h. NFP-LAM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
i. NFP-BBT - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
j. NFP-CMM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
k. NFP-STM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
l. NFP-SDM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
m. Total Current Users 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
Section B. Maternal Care
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
1. No. of pregnant women w/
at least 4 prenatal check-
ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
2. No. of pregnant women
assessed of their nutritional
status during the 1st tri. -Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
c. No. of pregnant women
seen in the first trimester
who have high BMI - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
3. No. of pregnant women for
the first time given 2 doses of
Td vaccination - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
4. No. of pregnant women for
the 2nd or more times given
at least 3 doses of Td
vaccination (Td2 Plus) - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
5. No. of pregnant women who
completed the dose of iron
with folic acid
supplementation - Total 0 0 0 0
 • NHTS 0
• Non-NHTS 0
6. No. of pregnant women who
completed doses of calcium
carbonate supplementation -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
12. No. of pregnant women
tested positive for Hepatitis
B - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
13. No. of pregnant women
screened for HIV - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
14. No. of pregnant women
tested for CBC or Hgb&Hct
count - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
15. No. of pregnant women
tested for CBC or Hgb&Hct
count diagnosed with
anemia - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
16. No. of pregnant women
screened for gestational
diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
17.   No. of pregnant women
tested positive for
gestational diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col 3)  (Col. 4)
 Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
a. No. of deliveries attended
by a doctor - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by a nurse – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
c. No. of deliveries attended
by midwives - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
22. No. of deliveries attended by
non-skilled health
professionals - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
a. No. of deliveries attended
by Hilot/TBA - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by others - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
23. No. of health facility-based
deliveries - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
27c. No. of fetal deaths - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
27d. No. of abortion/
miscarriage - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0

Section C. Child Care a

Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
C1. Immunization Services
1. CPAB - Total 0 0 0 6. DPT-HiB-HepB 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
2. BCG - Total 0 0 0 7. OPV 1 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
3. HepB, within 24 hours. - Total 0 0 0 8. OPV 2 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
4. DPT-HiB-HepB 1 - Total 0 0 0 9. OPV 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
5. DPT-HiB-HepB 2 - Total 0 0 0 10. IPV - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
16. FIC - Total 0 0 0 18. Td, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
17. CIC - Total 0 0 0 19. MR, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
C2. Nutrition Services
22. Newborns initiated on breastfeeding
immediately after birth lasting to 90 mins - 28. Infants 6-11 mos. old seen - Total
Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
23. Preterm/LBW infants given iron 29. Infants 6-11 mos. given 1 dose of
supplementation - Total 0 0 0 Vitamin A 100,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
24. Infants 6 mos. old seen - Total 0 0 0 30. Children 12-59 mos seen - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
25. Infants exclusively breastfed until 6th month - 31. Children 12-59 mos. old given 2
Total 0 0 0 doses of Vitamin A 200,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
26. Infants 6 mos. old initiated to complementary 32. Infant 6-11 months old who completed
feeding with continued breastfeeding - Total 0 0 0 MNP supplementation - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
27. Infants 6 mos. old initiated to complementary
feeding but no longer or never been breastfed 33. Children 12-23 mos. seen - Total
- Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
0
40. 1-19 y/o given 2 doses of deworming drug - 42. SAC, 5-9 y/o dewormed (2 doses) -
Total 0 0 0 Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
41. PSAC, 1-4 y/o dewormed (2 doses) - Total 0 0 0
• NHTS 0
• Non-NHTS 0
0
44. Sick Infants 6-11 mos. old seen - Total 47. Sick Children 12-59 mos. old
0 0 0 received Vitamin A - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
45. Sick Infants 6-11 mos. old received 48. Diarrhea cases 0-59 months old seen
Vitamin A - Total 0 0 0 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
49. Diarrhea cases 0-59 months old
46. Sick Children 12-59 mos. old seen - Total
0 0 0 received ORS - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
 To be submitted Qua
Section E. Infectious Disease Preven
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
E1. Filariasis Prevention and Control E2. Schistosomiasis Prevention and Contro
1. No. of individual examined for lymphatic 1. No. of people 5-65 y/o who ingested
filariasis - Total 0 MDA drugs - Total
2. No. of individual examined found positive for 2. No. of patients seen - Total
lymphatic filariasis - Total 0 3. No. of suspected cases seen
3. No. of lymphatic filariasis cases examined with 4. No. acute clinically diagnosed cases -
manifestation of either lymphedema,hydrocele, Total
elephantiasis - Total
0 5. No. of confirmed acute cases - Total
6. No. of chronic clinically diagnosed
cases - Total
Section F. _________________________
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
 ___JANUARY_____ YEAR: ____2020___

M1
AGPAKO__________________________
_________________________
_________________________

BRGY
________________________
________________________
r submission to RHU/MHC

Services and Deworming for Women of Reproductive Age

Total A3. Deworming Services SES Total

Col. 3) (Col. 1) (Col. 2) (Col. 3)

NHTS Non-NHTS
1. No. of women 20-49 years old given 2 doses of
15 deworming drugs - Total
0 0 0
15
0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
on B. Maternal Care and Services
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

a. Number of pregnant women seen in the

first trimester who have normal BMI -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of pregnant women seen in the first
trimester who have low BMI - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

7. No. of pregnant women given iodine

capsules – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
8. No. of pregnant women given one dose
of deworming tablet - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
9. No. of pregnant women screened for
syphilis - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
10. No. of pregnant women tested positive
for syphilis - Total

0 0 0 0
 • NHTS 0
• Non-NHTS 0
11. No. of pregnant women screened for
Hepatitis B - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
18. No. of deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
19. No. of live births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20a. No. of live births with normal birth
weight - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20b. No. of live births with low birth weight
- Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
20c. No. of live births with unknown birth
weight- Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
21. No. of deliveries attended by skilled
health professionals - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col 3)  (Col. 4)
rks Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

24a. No. of deliveries in public health

facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
24b. No. of deliveries in private health
facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
25. No. of non-facility-based deliveries -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
26a. No. of vaginal deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
26b. No. of deliveries by cesarean
section – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
27a. No. of full-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
27b. No. of pre-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B3. Postpartum and Newborn Care
28. No. of postpartum women together
with their newborn who completed at
least 2 postpartum check-ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
 29. No. of postpartum women who
completed iron with folic acid
supplementation - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
30. No. of postpartum women with
Vitamin A supplementation – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
ction C. Child Care and Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)

epB 3 - Total 0 0 0 11. PCV 1 - Total 0 0

0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 12. PCV 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 13. PCV 3 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 14. MMR 1 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
0 0 0 15. MMR 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
1 (November) - Total 0 0 0 20. Td, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
e 1 (November) - Total 0 0 0 21. MR, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

34. Children 12-23 mos. who completed

1 mos. old seen - Total
MNP supplementation - Total
0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
 1 mos. given 1 dose of
35. Children 0-59 mos. seen - Total
100,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos seen - Total 0 0 0 36. Stunted - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos. old given 2
37. Wasted - Total
tamin A 200,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
1 months old who completed
38. Overweight/Obese - Total
lementation - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS

2-23 mos. seen - Total 39. Normal - Total

0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col. 1) (Col 2) (Col 3)

y/o dewormed (2 doses) - 43. Adolescents, 10-19 y/o dewormed

0 0 0 (2 doses) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

ren 12-59 mos. old 50. Diarrhea cases 0-59 mos. received
itamin A - Total 0 0 0 ORS w/ zinc - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old seen 51. Pneumonia cases 0-59 mos. old
0 0 0 seen - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old 52. Pneumonia cases 0-59 mos. old
ORS - Total 0 0 0 completed treatment - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
 To be submitted Quarterly
ous Disease Prevention and Control Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
miasis Prevention and Control E2. Schistosomiasis Prevention and Control (Con't.)
le 5-65 y/o who ingested 7. No. confirmed chronic cases - Total
- Total 0
nts seen - Total 0 8. No. of confirmed cases (acute and
ected cases seen 0 chronic) - Total
clinically diagnosed cases - 9. No. of cases treated - Total
0
rmed acute cases - Total 0 10. No. of confirmed chronic cases
nic clinically diagnosed referred to a hospital facility - Total
al 0
_________________________________________
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
M1
RGY
Total

(Col. 3)

New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
 0 0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0 0
0
0
0 0
0
0
0 0
0
0
 0 0
0
0

Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
 Total
(Col 4)

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Total
(Col 4)
0
0
0
0
0
0

0
0
0
 0
0
0
0
0
0

0
0
0

0
0
0

0
0
0
Total
(Col 4)

0
0
0

0
0
0

0
0
0

0
0
0
 Total
(Col 4)
't.)

Total
(Col 4)
 FHSIS REPORT for the MONTH: ___JANUARY_____
Name of Barangay: _____TAGPAKO_________
Name of BHS: _______________________
Name of Municipality/City: _______________________
Name of Province: ________________________
Projected Population of the Year: _______________________
For submission to RHU/MHC

Section A. Family Planning Services and Dewor

A1. Modern FP Unmet Need Age Total

(Col. 1) (Col. 2) (Col. 3)

10-14 15-19 20-49
1. No. of WRA with unmet
need for modern FP - Total 5 5 5
15
• NHTS 5 5 5 15
• Non-NHTS 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
a. Female Sterilization/ BTL - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
b. Male Sterilization/ NSV-Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
c. Condom - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d. Pills - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
 d.1 Pills-POP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d.2 Pills-COC - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
e. Injectables (DMPA/ POI) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
f. Implant - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g. IUD (IUD-I and IUD-PP) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.1 IUD-I- Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.2 IUD-PP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
h. NFP-LAM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
i. NFP-BBT - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
j. NFP-CMM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
k. NFP-STM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
l. NFP-SDM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
m. Total Current Users 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
Section B. Maternal Care
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
1. No. of pregnant women w/
at least 4 prenatal check-
ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
2. No. of pregnant women
assessed of their nutritional
status during the 1st tri. -Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
c. No. of pregnant women
seen in the first trimester
who have high BMI - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
3. No. of pregnant women for
the first time given 2 doses of
Td vaccination - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
4. No. of pregnant women for
the 2nd or more times given
at least 3 doses of Td
vaccination (Td2 Plus) - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
5. No. of pregnant women who
completed the dose of iron
with folic acid
supplementation - Total 0 0 0 0
 • NHTS 0
• Non-NHTS 0
6. No. of pregnant women who
completed doses of calcium
carbonate supplementation -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
12. No. of pregnant women
tested positive for Hepatitis
B - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
13. No. of pregnant women
screened for HIV - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
14. No. of pregnant women
tested for CBC or Hgb&Hct
count - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
15. No. of pregnant women
tested for CBC or Hgb&Hct
count diagnosed with
anemia - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
16. No. of pregnant women
screened for gestational
diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
17.   No. of pregnant women
tested positive for
gestational diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col 3)  (Col. 4)
 Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
a. No. of deliveries attended
by a doctor - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by a nurse – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
c. No. of deliveries attended
by midwives - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
22. No. of deliveries attended by
non-skilled health
professionals - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
a. No. of deliveries attended
by Hilot/TBA - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by others - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
23. No. of health facility-based
deliveries - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
27c. No. of fetal deaths - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
27d. No. of abortion/
miscarriage - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0

Section C. Child Care a

Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
C1. Immunization Services
1. CPAB - Total 0 0 0 6. DPT-HiB-HepB 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
2. BCG - Total 0 0 0 7. OPV 1 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
3. HepB, within 24 hours. - Total 0 0 0 8. OPV 2 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
4. DPT-HiB-HepB 1 - Total 0 0 0 9. OPV 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
5. DPT-HiB-HepB 2 - Total 0 0 0 10. IPV - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
16. FIC - Total 0 0 0 18. Td, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
17. CIC - Total 0 0 0 19. MR, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
C2. Nutrition Services
22. Newborns initiated on breastfeeding
immediately after birth lasting to 90 mins - 28. Infants 6-11 mos. old seen - Total
Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
23. Preterm/LBW infants given iron 29. Infants 6-11 mos. given 1 dose of
supplementation - Total 0 0 0 Vitamin A 100,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
24. Infants 6 mos. old seen - Total 0 0 0 30. Children 12-59 mos seen - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
25. Infants exclusively breastfed until 6th month - 31. Children 12-59 mos. old given 2
Total 0 0 0 doses of Vitamin A 200,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
26. Infants 6 mos. old initiated to complementary 32. Infant 6-11 months old who completed
feeding with continued breastfeeding - Total 0 0 0 MNP supplementation - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
27. Infants 6 mos. old initiated to complementary
feeding but no longer or never been breastfed 33. Children 12-23 mos. seen - Total
- Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
0
40. 1-19 y/o given 2 doses of deworming drug - 42. SAC, 5-9 y/o dewormed (2 doses) -
Total 0 0 0 Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
41. PSAC, 1-4 y/o dewormed (2 doses) - Total 0 0 0
• NHTS 0
• Non-NHTS 0
0
44. Sick Infants 6-11 mos. old seen - Total 47. Sick Children 12-59 mos. old
0 0 0 received Vitamin A - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
45. Sick Infants 6-11 mos. old received 48. Diarrhea cases 0-59 months old seen
Vitamin A - Total 0 0 0 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
49. Diarrhea cases 0-59 months old
46. Sick Children 12-59 mos. old seen - Total
0 0 0 received ORS - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
 To be submitted Qua
Section E. Infectious Disease Preven
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
E1. Filariasis Prevention and Control E2. Schistosomiasis Prevention and Contro
1. No. of individual examined for lymphatic 1. No. of people 5-65 y/o who ingested
filariasis - Total 0 MDA drugs - Total
2. No. of individual examined found positive for 2. No. of patients seen - Total
lymphatic filariasis - Total 0 3. No. of suspected cases seen
3. No. of lymphatic filariasis cases examined with 4. No. acute clinically diagnosed cases -
manifestation of either lymphedema,hydrocele, Total
elephantiasis - Total
0 5. No. of confirmed acute cases - Total
6. No. of chronic clinically diagnosed
cases - Total
Section F. _________________________
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
 ___JANUARY_____ YEAR: ____2020___

M1
AGPAKO__________________________
_________________________
_________________________

BRGY
________________________
________________________
r submission to RHU/MHC

Services and Deworming for Women of Reproductive Age

Total A3. Deworming Services SES Total

Col. 3) (Col. 1) (Col. 2) (Col. 3)

NHTS Non-NHTS
1. No. of women 20-49 years old given 2 doses of
15 deworming drugs - Total
0 0 0
15
0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
on B. Maternal Care and Services
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

a. Number of pregnant women seen in the

first trimester who have normal BMI -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of pregnant women seen in the first
trimester who have low BMI - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

7. No. of pregnant women given iodine

capsules – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
8. No. of pregnant women given one dose
of deworming tablet - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
9. No. of pregnant women screened for
syphilis - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
10. No. of pregnant women tested positive
for syphilis - Total

0 0 0 0
 • NHTS 0
• Non-NHTS 0
11. No. of pregnant women screened for
Hepatitis B - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
18. No. of deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
19. No. of live births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20a. No. of live births with normal birth
weight - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20b. No. of live births with low birth weight
- Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
20c. No. of live births with unknown birth
weight- Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
21. No. of deliveries attended by skilled
health professionals - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col 3)  (Col. 4)
rks Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

24a. No. of deliveries in public health

facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
24b. No. of deliveries in private health
facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
25. No. of non-facility-based deliveries -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
26a. No. of vaginal deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
26b. No. of deliveries by cesarean
section – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
27a. No. of full-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
27b. No. of pre-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B3. Postpartum and Newborn Care
28. No. of postpartum women together
with their newborn who completed at
least 2 postpartum check-ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
 29. No. of postpartum women who
completed iron with folic acid
supplementation - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
30. No. of postpartum women with
Vitamin A supplementation – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
ction C. Child Care and Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)

epB 3 - Total 0 0 0 11. PCV 1 - Total 0 0

0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 12. PCV 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 13. PCV 3 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 14. MMR 1 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
0 0 0 15. MMR 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
1 (November) - Total 0 0 0 20. Td, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
e 1 (November) - Total 0 0 0 21. MR, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

34. Children 12-23 mos. who completed

1 mos. old seen - Total
MNP supplementation - Total
0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
 1 mos. given 1 dose of
35. Children 0-59 mos. seen - Total
100,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos seen - Total 0 0 0 36. Stunted - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos. old given 2
37. Wasted - Total
tamin A 200,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
1 months old who completed
38. Overweight/Obese - Total
lementation - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS

2-23 mos. seen - Total 39. Normal - Total

0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col. 1) (Col 2) (Col 3)

y/o dewormed (2 doses) - 43. Adolescents, 10-19 y/o dewormed

0 0 0 (2 doses) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

ren 12-59 mos. old 50. Diarrhea cases 0-59 mos. received
itamin A - Total 0 0 0 ORS w/ zinc - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old seen 51. Pneumonia cases 0-59 mos. old
0 0 0 seen - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old 52. Pneumonia cases 0-59 mos. old
ORS - Total 0 0 0 completed treatment - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
 To be submitted Quarterly
ous Disease Prevention and Control Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
miasis Prevention and Control E2. Schistosomiasis Prevention and Control (Con't.)
le 5-65 y/o who ingested 7. No. confirmed chronic cases - Total
- Total 0
nts seen - Total 0 8. No. of confirmed cases (acute and
ected cases seen 0 chronic) - Total
clinically diagnosed cases - 9. No. of cases treated - Total
0
rmed acute cases - Total 0 10. No. of confirmed chronic cases
nic clinically diagnosed referred to a hospital facility - Total
al 0
_________________________________________
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
M1
RGY
Total

(Col. 3)

New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
 0 0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0 0
0
0
0 0
0
0
0 0
0
0
 0 0
0
0

Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
 Total
(Col 4)

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Total
(Col 4)
0
0
0
0
0
0

0
0
0
 0
0
0
0
0
0

0
0
0

0
0
0

0
0
0
Total
(Col 4)

0
0
0

0
0
0

0
0
0

0
0
0
 Total
(Col 4)
't.)

Total
(Col 4)
 FHSIS REPORT for the MONTH: ___JANUARY_____
Name of Barangay: _____TAGPAKO_________
Name of BHS: _______________________
Name of Municipality/City: _______________________
Name of Province: ________________________
Projected Population of the Year: _______________________
For submission to RHU/MHC

Section A. Family Planning Services and Dewor

A1. Modern FP Unmet Need Age Total

(Col. 1) (Col. 2) (Col. 3)

10-14 15-19 20-49
1. No. of WRA with unmet
need for modern FP - Total 5 5 5
15
• NHTS 5 5 5 15
• Non-NHTS 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
a. Female Sterilization/ BTL - 5 0 0 0 0 0 0
Total 5 0
• NHTS 0 0
• Non-NHTS 5 5 0
b. Male Sterilization/ NSV-Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
c. Condom - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d. Pills - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
 d.1 Pills-POP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d.2 Pills-COC - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
e. Injectables (DMPA/ POI) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
f. Implant - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g. IUD (IUD-I and IUD-PP) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.1 IUD-I- Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.2 IUD-PP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
h. NFP-LAM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
i. NFP-BBT - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
j. NFP-CMM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
k. NFP-STM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
l. NFP-SDM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
m. Total Current Users 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
Section B. Maternal Care
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
1. No. of pregnant women w/
at least 4 prenatal check-
ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
2. No. of pregnant women
assessed of their nutritional
status during the 1st tri. -Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
c. No. of pregnant women
seen in the first trimester
who have high BMI - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
3. No. of pregnant women for
the first time given 2 doses of
Td vaccination - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
4. No. of pregnant women for
the 2nd or more times given
at least 3 doses of Td
vaccination (Td2 Plus) - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
5. No. of pregnant women who
completed the dose of iron
with folic acid
supplementation - Total 0 0 0 0
 • NHTS 0
• Non-NHTS 0
6. No. of pregnant women who
completed doses of calcium
carbonate supplementation -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
12. No. of pregnant women
tested positive for Hepatitis
B - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
13. No. of pregnant women
screened for HIV - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
14. No. of pregnant women
tested for CBC or Hgb&Hct
count - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
15. No. of pregnant women
tested for CBC or Hgb&Hct
count diagnosed with
anemia - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
16. No. of pregnant women
screened for gestational
diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
17.   No. of pregnant women
tested positive for
gestational diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col 3)  (Col. 4)
 Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
a. No. of deliveries attended
by a doctor - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by a nurse – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
c. No. of deliveries attended
by midwives - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
22. No. of deliveries attended by
non-skilled health
professionals - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
a. No. of deliveries attended
by Hilot/TBA - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by others - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
23. No. of health facility-based
deliveries - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
27c. No. of fetal deaths - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
27d. No. of abortion/
miscarriage - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0

Section C. Child Care a

Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
C1. Immunization Services
1. CPAB - Total 0 0 0 6. DPT-HiB-HepB 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
2. BCG - Total 0 0 0 7. OPV 1 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
3. HepB, within 24 hours. - Total 0 0 0 8. OPV 2 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
4. DPT-HiB-HepB 1 - Total 0 0 0 9. OPV 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
5. DPT-HiB-HepB 2 - Total 0 0 0 10. IPV - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
16. FIC - Total 0 0 0 18. Td, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
17. CIC - Total 0 0 0 19. MR, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
C2. Nutrition Services
22. Newborns initiated on breastfeeding
immediately after birth lasting to 90 mins - 28. Infants 6-11 mos. old seen - Total
Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
23. Preterm/LBW infants given iron 29. Infants 6-11 mos. given 1 dose of
supplementation - Total 0 0 0 Vitamin A 100,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
24. Infants 6 mos. old seen - Total 0 0 0 30. Children 12-59 mos seen - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
25. Infants exclusively breastfed until 6th month - 31. Children 12-59 mos. old given 2
Total 0 0 0 doses of Vitamin A 200,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
26. Infants 6 mos. old initiated to complementary 32. Infant 6-11 months old who completed
feeding with continued breastfeeding - Total 0 0 0 MNP supplementation - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
27. Infants 6 mos. old initiated to complementary
feeding but no longer or never been breastfed 33. Children 12-23 mos. seen - Total
- Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
0
40. 1-19 y/o given 2 doses of deworming drug - 42. SAC, 5-9 y/o dewormed (2 doses) -
Total 0 0 0 Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
41. PSAC, 1-4 y/o dewormed (2 doses) - Total 0 0 0
• NHTS 0
• Non-NHTS 0
0
44. Sick Infants 6-11 mos. old seen - Total 47. Sick Children 12-59 mos. old
0 0 0 received Vitamin A - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
45. Sick Infants 6-11 mos. old received 48. Diarrhea cases 0-59 months old seen
Vitamin A - Total 0 0 0 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
49. Diarrhea cases 0-59 months old
46. Sick Children 12-59 mos. old seen - Total
0 0 0 received ORS - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
 To be submitted Qua
Section E. Infectious Disease Preven
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
E1. Filariasis Prevention and Control E2. Schistosomiasis Prevention and Contro
1. No. of individual examined for lymphatic 1. No. of people 5-65 y/o who ingested
filariasis - Total 0 MDA drugs - Total
2. No. of individual examined found positive for 2. No. of patients seen - Total
lymphatic filariasis - Total 0 3. No. of suspected cases seen
3. No. of lymphatic filariasis cases examined with 4. No. acute clinically diagnosed cases -
manifestation of either lymphedema,hydrocele, Total
elephantiasis - Total
0 5. No. of confirmed acute cases - Total
6. No. of chronic clinically diagnosed
cases - Total
Section F. _________________________
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
 ___JANUARY_____ YEAR: ____2020___

M1
AGPAKO__________________________
_________________________
_________________________

BRGY
________________________
________________________
r submission to RHU/MHC

Services and Deworming for Women of Reproductive Age

Total A3. Deworming Services SES Total

Col. 3) (Col. 1) (Col. 2) (Col. 3)

NHTS Non-NHTS
1. No. of women 20-49 years old given 2 doses of
15 deworming drugs - Total
0 0 0
15
0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
on B. Maternal Care and Services
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

a. Number of pregnant women seen in the

first trimester who have normal BMI -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of pregnant women seen in the first
trimester who have low BMI - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

7. No. of pregnant women given iodine

capsules – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
8. No. of pregnant women given one dose
of deworming tablet - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
9. No. of pregnant women screened for
syphilis - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
10. No. of pregnant women tested positive
for syphilis - Total

0 0 0 0
 • NHTS 0
• Non-NHTS 0
11. No. of pregnant women screened for
Hepatitis B - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
18. No. of deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
19. No. of live births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20a. No. of live births with normal birth
weight - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20b. No. of live births with low birth weight
- Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
20c. No. of live births with unknown birth
weight- Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
21. No. of deliveries attended by skilled
health professionals - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col 3)  (Col. 4)
rks Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

24a. No. of deliveries in public health

facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
24b. No. of deliveries in private health
facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
25. No. of non-facility-based deliveries -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
26a. No. of vaginal deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
26b. No. of deliveries by cesarean
section – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
27a. No. of full-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
27b. No. of pre-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B3. Postpartum and Newborn Care
28. No. of postpartum women together
with their newborn who completed at
least 2 postpartum check-ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
 29. No. of postpartum women who
completed iron with folic acid
supplementation - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
30. No. of postpartum women with
Vitamin A supplementation – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
ction C. Child Care and Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)

epB 3 - Total 0 0 0 11. PCV 1 - Total 0 0

0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 12. PCV 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 13. PCV 3 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 14. MMR 1 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
0 0 0 15. MMR 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
1 (November) - Total 0 0 0 20. Td, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
e 1 (November) - Total 0 0 0 21. MR, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

34. Children 12-23 mos. who completed

1 mos. old seen - Total
MNP supplementation - Total
0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
 1 mos. given 1 dose of
35. Children 0-59 mos. seen - Total
100,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos seen - Total 0 0 0 36. Stunted - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos. old given 2
37. Wasted - Total
tamin A 200,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
1 months old who completed
38. Overweight/Obese - Total
lementation - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS

2-23 mos. seen - Total 39. Normal - Total

0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col. 1) (Col 2) (Col 3)

y/o dewormed (2 doses) - 43. Adolescents, 10-19 y/o dewormed

0 0 0 (2 doses) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

ren 12-59 mos. old 50. Diarrhea cases 0-59 mos. received
itamin A - Total 0 0 0 ORS w/ zinc - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old seen 51. Pneumonia cases 0-59 mos. old
0 0 0 seen - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old 52. Pneumonia cases 0-59 mos. old
ORS - Total 0 0 0 completed treatment - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
 To be submitted Quarterly
ous Disease Prevention and Control Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
miasis Prevention and Control E2. Schistosomiasis Prevention and Control (Con't.)
le 5-65 y/o who ingested 7. No. confirmed chronic cases - Total
- Total 0
nts seen - Total 0 8. No. of confirmed cases (acute and
ected cases seen 0 chronic) - Total
clinically diagnosed cases - 9. No. of cases treated - Total
0
rmed acute cases - Total 0 10. No. of confirmed chronic cases
nic clinically diagnosed referred to a hospital facility - Total
al 0
_________________________________________
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
M1
RGY
Total

(Col. 3)

New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
 0 0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0 0
0
0
0 0
0
0
0 0
0
0
 0 0
0
0

Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
 Total
(Col 4)

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Total
(Col 4)
0
0
0
0
0
0

0
0
0
 0
0
0
0
0
0

0
0
0

0
0
0

0
0
0
Total
(Col 4)

0
0
0

0
0
0

0
0
0

0
0
0
 Total
(Col 4)
't.)

Total
(Col 4)
 FHSIS REPORT for the MONTH: ___JANUARY_____
Name of Barangay: _____TAGPAKO_________
Name of BHS: _______________________
Name of Municipality/City: _______________________
Name of Province: ________________________
Projected Population of the Year: _______________________
For submission to RHU/MHC

Section A. Family Planning Services and Dewor

A1. Modern FP Unmet Need Age Total

(Col. 1) (Col. 2) (Col. 3)

10-14 15-19 20-49
1. No. of WRA with unmet
need for modern FP - Total 5 5 5
15
• NHTS 5 5 5 15
• Non-NHTS 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
a. Female Sterilization/ BTL - 5 0 0 0 0 0 0
Total 5 0
• NHTS 0 0
• Non-NHTS 5 5 0
b. Male Sterilization/ NSV-Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
c. Condom - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d. Pills - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
 d.1 Pills-POP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d.2 Pills-COC - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
e. Injectables (DMPA/ POI) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
f. Implant - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g. IUD (IUD-I and IUD-PP) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.1 IUD-I- Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.2 IUD-PP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
h. NFP-LAM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
i. NFP-BBT - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
j. NFP-CMM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
k. NFP-STM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
l. NFP-SDM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
m. Total Current Users 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
Section B. Maternal Care
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
1. No. of pregnant women w/
at least 4 prenatal check-
ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
2. No. of pregnant women
assessed of their nutritional
status during the 1st tri. -Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
c. No. of pregnant women
seen in the first trimester
who have high BMI - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
3. No. of pregnant women for
the first time given 2 doses of
Td vaccination - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
4. No. of pregnant women for
the 2nd or more times given
at least 3 doses of Td
vaccination (Td2 Plus) - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
5. No. of pregnant women who
completed the dose of iron
with folic acid
supplementation - Total 0 0 0 0
 • NHTS 0
• Non-NHTS 0
6. No. of pregnant women who
completed doses of calcium
carbonate supplementation -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
12. No. of pregnant women
tested positive for Hepatitis
B - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
13. No. of pregnant women
screened for HIV - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
14. No. of pregnant women
tested for CBC or Hgb&Hct
count - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
15. No. of pregnant women
tested for CBC or Hgb&Hct
count diagnosed with
anemia - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
16. No. of pregnant women
screened for gestational
diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
17.   No. of pregnant women
tested positive for
gestational diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col 3)  (Col. 4)
 Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
a. No. of deliveries attended
by a doctor - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by a nurse – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
c. No. of deliveries attended
by midwives - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
22. No. of deliveries attended by
non-skilled health
professionals - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
a. No. of deliveries attended
by Hilot/TBA - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by others - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
23. No. of health facility-based
deliveries - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
27c. No. of fetal deaths - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
27d. No. of abortion/
miscarriage - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0

Section C. Child Care a

Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
C1. Immunization Services
1. CPAB - Total 0 0 0 6. DPT-HiB-HepB 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
2. BCG - Total 0 0 0 7. OPV 1 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
3. HepB, within 24 hours. - Total 0 0 0 8. OPV 2 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
4. DPT-HiB-HepB 1 - Total 0 0 0 9. OPV 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
5. DPT-HiB-HepB 2 - Total 0 0 0 10. IPV - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
16. FIC - Total 0 0 0 18. Td, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
17. CIC - Total 0 0 0 19. MR, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
C2. Nutrition Services
22. Newborns initiated on breastfeeding
immediately after birth lasting to 90 mins - 28. Infants 6-11 mos. old seen - Total
Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
23. Preterm/LBW infants given iron 29. Infants 6-11 mos. given 1 dose of
supplementation - Total 0 0 0 Vitamin A 100,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
24. Infants 6 mos. old seen - Total 0 0 0 30. Children 12-59 mos seen - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
25. Infants exclusively breastfed until 6th month - 31. Children 12-59 mos. old given 2
Total 0 0 0 doses of Vitamin A 200,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
26. Infants 6 mos. old initiated to complementary 32. Infant 6-11 months old who completed
feeding with continued breastfeeding - Total 0 0 0 MNP supplementation - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
27. Infants 6 mos. old initiated to complementary
feeding but no longer or never been breastfed 33. Children 12-23 mos. seen - Total
- Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
0
40. 1-19 y/o given 2 doses of deworming drug - 42. SAC, 5-9 y/o dewormed (2 doses) -
Total 0 0 0 Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
41. PSAC, 1-4 y/o dewormed (2 doses) - Total 0 0 0
• NHTS 0
• Non-NHTS 0
0
44. Sick Infants 6-11 mos. old seen - Total 47. Sick Children 12-59 mos. old
0 0 0 received Vitamin A - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
45. Sick Infants 6-11 mos. old received 48. Diarrhea cases 0-59 months old seen
Vitamin A - Total 0 0 0 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
49. Diarrhea cases 0-59 months old
46. Sick Children 12-59 mos. old seen - Total
0 0 0 received ORS - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
 To be submitted Qua
Section E. Infectious Disease Preven
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
E1. Filariasis Prevention and Control E2. Schistosomiasis Prevention and Contro
1. No. of individual examined for lymphatic 1. No. of people 5-65 y/o who ingested
filariasis - Total 0 MDA drugs - Total
2. No. of individual examined found positive for 2. No. of patients seen - Total
lymphatic filariasis - Total 0 3. No. of suspected cases seen
3. No. of lymphatic filariasis cases examined with 4. No. acute clinically diagnosed cases -
manifestation of either lymphedema,hydrocele, Total
elephantiasis - Total
0 5. No. of confirmed acute cases - Total
6. No. of chronic clinically diagnosed
cases - Total
Section F. _________________________
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
 ___JANUARY_____ YEAR: ____2020___

M1
AGPAKO__________________________
_________________________
_________________________

BRGY
________________________
________________________
r submission to RHU/MHC

Services and Deworming for Women of Reproductive Age

Total A3. Deworming Services SES Total

Col. 3) (Col. 1) (Col. 2) (Col. 3)

NHTS Non-NHTS
1. No. of women 20-49 years old given 2 doses of
15 deworming drugs - Total
0 0 0
15
0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
on B. Maternal Care and Services
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

a. Number of pregnant women seen in the

first trimester who have normal BMI -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of pregnant women seen in the first
trimester who have low BMI - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

7. No. of pregnant women given iodine

capsules – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
8. No. of pregnant women given one dose
of deworming tablet - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
9. No. of pregnant women screened for
syphilis - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
10. No. of pregnant women tested positive
for syphilis - Total

0 0 0 0
 • NHTS 0
• Non-NHTS 0
11. No. of pregnant women screened for
Hepatitis B - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
18. No. of deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
19. No. of live births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20a. No. of live births with normal birth
weight - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20b. No. of live births with low birth weight
- Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
20c. No. of live births with unknown birth
weight- Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
21. No. of deliveries attended by skilled
health professionals - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col 3)  (Col. 4)
rks Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

24a. No. of deliveries in public health

facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
24b. No. of deliveries in private health
facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
25. No. of non-facility-based deliveries -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
26a. No. of vaginal deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
26b. No. of deliveries by cesarean
section – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
27a. No. of full-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
27b. No. of pre-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B3. Postpartum and Newborn Care
28. No. of postpartum women together
with their newborn who completed at
least 2 postpartum check-ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
 29. No. of postpartum women who
completed iron with folic acid
supplementation - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
30. No. of postpartum women with
Vitamin A supplementation – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
ction C. Child Care and Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)

epB 3 - Total 0 0 0 11. PCV 1 - Total 0 0

0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 12. PCV 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 13. PCV 3 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 14. MMR 1 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
0 0 0 15. MMR 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
1 (November) - Total 0 0 0 20. Td, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
e 1 (November) - Total 0 0 0 21. MR, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

34. Children 12-23 mos. who completed

1 mos. old seen - Total
MNP supplementation - Total
0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
 1 mos. given 1 dose of
35. Children 0-59 mos. seen - Total
100,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos seen - Total 0 0 0 36. Stunted - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos. old given 2
37. Wasted - Total
tamin A 200,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
1 months old who completed
38. Overweight/Obese - Total
lementation - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS

2-23 mos. seen - Total 39. Normal - Total

0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col. 1) (Col 2) (Col 3)

y/o dewormed (2 doses) - 43. Adolescents, 10-19 y/o dewormed

0 0 0 (2 doses) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

ren 12-59 mos. old 50. Diarrhea cases 0-59 mos. received
itamin A - Total 0 0 0 ORS w/ zinc - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old seen 51. Pneumonia cases 0-59 mos. old
0 0 0 seen - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old 52. Pneumonia cases 0-59 mos. old
ORS - Total 0 0 0 completed treatment - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
 To be submitted Quarterly
ous Disease Prevention and Control Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
miasis Prevention and Control E2. Schistosomiasis Prevention and Control (Con't.)
le 5-65 y/o who ingested 7. No. confirmed chronic cases - Total
- Total 0
nts seen - Total 0 8. No. of confirmed cases (acute and
ected cases seen 0 chronic) - Total
clinically diagnosed cases - 9. No. of cases treated - Total
0
rmed acute cases - Total 0 10. No. of confirmed chronic cases
nic clinically diagnosed referred to a hospital facility - Total
al 0
_________________________________________
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
M1
RGY
Total

(Col. 3)

New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
 0 0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0 0
0
0
0 0
0
0
0 0
0
0
 0 0
0
0

Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
 Total
(Col 4)

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Total
(Col 4)
0
0
0
0
0
0

0
0
0
 0
0
0
0
0
0

0
0
0

0
0
0

0
0
0
Total
(Col 4)

0
0
0

0
0
0

0
0
0

0
0
0
 Total
(Col 4)
't.)

Total
(Col 4)
BRGY

FHSIS REPORT for the MONTH: ___JANUARY_____

Name of Barangay: _____TAGPAKO_________
Name of BHS: _______________________
Name of Municipality/City: _______________________
Name of Province: ________________________
Projected Population of the Year: _______________________
For submission to RHU/MHC

Section A. Family Planning Services and Dewor

A1. Modern FP Unmet Need Age Total

(Col. 1) (Col. 2) (Col. 3)

10-14 15-19 20-49
1. No. of WRA with unmet
need for modern FP - Total 5 5 5
15
• NHTS 5 5 5 15
• Non-NHTS 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
a. Female Sterilization/ BTL - 5 0 0 0 0 0 0
Total 5 0
• NHTS 0 0
• Non-NHTS 5 5 0
b. Male Sterilization/ NSV-Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
c. Condom - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d. Pills - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
 d.1 Pills-POP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d.2 Pills-COC - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
e. Injectables (DMPA/ POI) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
f. Implant - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g. IUD (IUD-I and IUD-PP) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.1 IUD-I- Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.2 IUD-PP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
h. NFP-LAM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
i. NFP-BBT - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
j. NFP-CMM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
k. NFP-STM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
l. NFP-SDM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
m. Total Current Users 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
Section B. Maternal Care
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
1. No. of pregnant women w/
at least 4 prenatal check-
ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
2. No. of pregnant women
assessed of their nutritional
status during the 1st tri. -Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
c. No. of pregnant women
seen in the first trimester
who have high BMI - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
3. No. of pregnant women for
the first time given 2 doses of
Td vaccination - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
4. No. of pregnant women for
the 2nd or more times given
at least 3 doses of Td
vaccination (Td2 Plus) - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
5. No. of pregnant women who
completed the dose of iron
with folic acid
supplementation - Total 0 0 0 0
 • NHTS 0
• Non-NHTS 0
6. No. of pregnant women who
completed doses of calcium
carbonate supplementation -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
12. No. of pregnant women
tested positive for Hepatitis
B - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
13. No. of pregnant women
screened for HIV - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
14. No. of pregnant women
tested for CBC or Hgb&Hct
count - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
15. No. of pregnant women
tested for CBC or Hgb&Hct
count diagnosed with
anemia - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
16. No. of pregnant women
screened for gestational
diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
17.   No. of pregnant women
tested positive for
gestational diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col 3)  (Col. 4)
 Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
a. No. of deliveries attended
by a doctor - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by a nurse – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
c. No. of deliveries attended
by midwives - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
22. No. of deliveries attended by
non-skilled health
professionals - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
a. No. of deliveries attended
by Hilot/TBA - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by others - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
23. No. of health facility-based
deliveries - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
27c. No. of fetal deaths - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
27d. No. of abortion/
miscarriage - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0

Section C. Child Care a

Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
C1. Immunization Services
1. CPAB - Total 0 0 0 6. DPT-HiB-HepB 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
2. BCG - Total 0 0 0 7. OPV 1 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
3. HepB, within 24 hours. - Total 0 0 0 8. OPV 2 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
4. DPT-HiB-HepB 1 - Total 0 0 0 9. OPV 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
5. DPT-HiB-HepB 2 - Total 0 0 0 10. IPV - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
16. FIC - Total 0 0 0 18. Td, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
17. CIC - Total 0 0 0 19. MR, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
C2. Nutrition Services
22. Newborns initiated on breastfeeding
immediately after birth lasting to 90 mins - 28. Infants 6-11 mos. old seen - Total
Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
23. Preterm/LBW infants given iron 29. Infants 6-11 mos. given 1 dose of
supplementation - Total 0 0 0 Vitamin A 100,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
24. Infants 6 mos. old seen - Total 0 0 0 30. Children 12-59 mos seen - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
25. Infants exclusively breastfed until 6th month - 31. Children 12-59 mos. old given 2
Total 0 0 0 doses of Vitamin A 200,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
26. Infants 6 mos. old initiated to complementary 32. Infant 6-11 months old who completed
feeding with continued breastfeeding - Total 0 0 0 MNP supplementation - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
27. Infants 6 mos. old initiated to complementary
feeding but no longer or never been breastfed 33. Children 12-23 mos. seen - Total
- Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
0
40. 1-19 y/o given 2 doses of deworming drug - 42. SAC, 5-9 y/o dewormed (2 doses) -
Total 0 0 0 Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
41. PSAC, 1-4 y/o dewormed (2 doses) - Total 0 0 0
• NHTS 0
• Non-NHTS 0
0
44. Sick Infants 6-11 mos. old seen - Total 47. Sick Children 12-59 mos. old
0 0 0 received Vitamin A - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
45. Sick Infants 6-11 mos. old received 48. Diarrhea cases 0-59 months old seen
Vitamin A - Total 0 0 0 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
49. Diarrhea cases 0-59 months old
46. Sick Children 12-59 mos. old seen - Total
0 0 0 received ORS - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
 To be submitted Qua
Section E. Infectious Disease Preven
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
E1. Filariasis Prevention and Control E2. Schistosomiasis Prevention and Contro
1. No. of individual examined for lymphatic 1. No. of people 5-65 y/o who ingested
filariasis - Total 0 MDA drugs - Total
2. No. of individual examined found positive for 2. No. of patients seen - Total
lymphatic filariasis - Total 0 3. No. of suspected cases seen
3. No. of lymphatic filariasis cases examined with 4. No. acute clinically diagnosed cases -
manifestation of either lymphedema,hydrocele, Total
elephantiasis - Total
0 5. No. of confirmed acute cases - Total
6. No. of chronic clinically diagnosed
cases - Total
Section F. _________________________
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
 ___JANUARY_____ YEAR: ____2020___

M1
AGPAKO__________________________
_________________________
_________________________

BRGY
________________________
________________________
r submission to RHU/MHC

Services and Deworming for Women of Reproductive Age

Total A3. Deworming Services SES Total

Col. 3) (Col. 1) (Col. 2) (Col. 3)

NHTS Non-NHTS
1. No. of women 20-49 years old given 2 doses of
15 deworming drugs - Total
0 0 0
15
0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
on B. Maternal Care and Services
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

a. Number of pregnant women seen in the

first trimester who have normal BMI -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of pregnant women seen in the first
trimester who have low BMI - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

7. No. of pregnant women given iodine

capsules – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
8. No. of pregnant women given one dose
of deworming tablet - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
9. No. of pregnant women screened for
syphilis - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
10. No. of pregnant women tested positive
for syphilis - Total

0 0 0 0
 • NHTS 0
• Non-NHTS 0
11. No. of pregnant women screened for
Hepatitis B - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
18. No. of deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
19. No. of live births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20a. No. of live births with normal birth
weight - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20b. No. of live births with low birth weight
- Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
20c. No. of live births with unknown birth
weight- Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
21. No. of deliveries attended by skilled
health professionals - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col 3)  (Col. 4)
rks Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

24a. No. of deliveries in public health

facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
24b. No. of deliveries in private health
facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
25. No. of non-facility-based deliveries -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
26a. No. of vaginal deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
26b. No. of deliveries by cesarean
section – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
27a. No. of full-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
27b. No. of pre-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B3. Postpartum and Newborn Care
28. No. of postpartum women together
with their newborn who completed at
least 2 postpartum check-ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
 29. No. of postpartum women who
completed iron with folic acid
supplementation - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
30. No. of postpartum women with
Vitamin A supplementation – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
ction C. Child Care and Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)

epB 3 - Total 0 0 0 11. PCV 1 - Total 0 0

0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 12. PCV 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 13. PCV 3 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 14. MMR 1 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
0 0 0 15. MMR 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
1 (November) - Total 0 0 0 20. Td, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
e 1 (November) - Total 0 0 0 21. MR, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

34. Children 12-23 mos. who completed

1 mos. old seen - Total
MNP supplementation - Total
0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
 1 mos. given 1 dose of
35. Children 0-59 mos. seen - Total
100,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos seen - Total 0 0 0 36. Stunted - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos. old given 2
37. Wasted - Total
tamin A 200,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
1 months old who completed
38. Overweight/Obese - Total
lementation - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS

2-23 mos. seen - Total 39. Normal - Total

0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col. 1) (Col 2) (Col 3)

y/o dewormed (2 doses) - 43. Adolescents, 10-19 y/o dewormed

0 0 0 (2 doses) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

ren 12-59 mos. old 50. Diarrhea cases 0-59 mos. received
itamin A - Total 0 0 0 ORS w/ zinc - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old seen 51. Pneumonia cases 0-59 mos. old
0 0 0 seen - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old 52. Pneumonia cases 0-59 mos. old
ORS - Total 0 0 0 completed treatment - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
 To be submitted Quarterly
ous Disease Prevention and Control Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
miasis Prevention and Control E2. Schistosomiasis Prevention and Control (Con't.)
le 5-65 y/o who ingested 7. No. confirmed chronic cases - Total
- Total 0
nts seen - Total 0 8. No. of confirmed cases (acute and
ected cases seen 0 chronic) - Total
clinically diagnosed cases - 9. No. of cases treated - Total
0
rmed acute cases - Total 0 10. No. of confirmed chronic cases
nic clinically diagnosed referred to a hospital facility - Total
al 0
_________________________________________
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
M1
RGY
Total

(Col. 3)

New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
 0 0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0 0
0
0
0 0
0
0
0 0
0
0
 0 0
0
0

Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
 Total
(Col 4)

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Total
(Col 4)
0
0
0
0
0
0

0
0
0
 0
0
0
0
0
0

0
0
0

0
0
0

0
0
0
Total
(Col 4)

0
0
0

0
0
0

0
0
0

0
0
0
 Total
(Col 4)
't.)

Total
(Col 4)
 FHSIS REPORT for the MONTH: ___JANUARY_____
Name of Barangay: _____TAGPAKO_________
Name of BHS: _______________________
Name of Municipality/City: _______________________
Name of Province: ________________________
Projected Population of the Year: _______________________
For submission to RHU/MHC

Section A. Family Planning Services and Dewor

A1. Modern FP Unmet Need Age Total

(Col. 1) (Col. 2) (Col. 3)

10-14 15-19 20-49
1. No. of WRA with unmet
need for modern FP - Total 5 5 5
15
• NHTS 5 5 5 15
• Non-NHTS 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
a. Female Sterilization/ BTL - 5 0 0 5 0 0 5
Total 5 5
• NHTS 0 0
• Non-NHTS 5 5 5 5 5
b. Male Sterilization/ NSV-Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
c. Condom - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d. Pills - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
 d.1 Pills-POP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
d.2 Pills-COC - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
e. Injectables (DMPA/ POI) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
f. Implant - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g. IUD (IUD-I and IUD-PP) - 0 0 0 0 0 0 0
Total 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.1 IUD-I- Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
g.2 IUD-PP - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
h. NFP-LAM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
i. NFP-BBT - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
j. NFP-CMM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
k. NFP-STM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
l. NFP-SDM - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
m. Total Current Users 0 0 0 0 0 0 0 0 0
• NHTS 0 0
• Non-NHTS 0 0
Section B. Maternal Care
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
1. No. of pregnant women w/
at least 4 prenatal check-
ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
2. No. of pregnant women
assessed of their nutritional
status during the 1st tri. -Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
c. No. of pregnant women
seen in the first trimester
who have high BMI - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
3. No. of pregnant women for
the first time given 2 doses of
Td vaccination - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
4. No. of pregnant women for
the 2nd or more times given
at least 3 doses of Td
vaccination (Td2 Plus) - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
5. No. of pregnant women who
completed the dose of iron
with folic acid
supplementation - Total 0 0 0 0
 • NHTS 0
• Non-NHTS 0
6. No. of pregnant women who
completed doses of calcium
carbonate supplementation -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
12. No. of pregnant women
tested positive for Hepatitis
B - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
13. No. of pregnant women
screened for HIV - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
14. No. of pregnant women
tested for CBC or Hgb&Hct
count - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
15. No. of pregnant women
tested for CBC or Hgb&Hct
count diagnosed with
anemia - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
16. No. of pregnant women
screened for gestational
diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
17.   No. of pregnant women
tested positive for
gestational diabetes – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col 3)  (Col. 4)
 Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
a. No. of deliveries attended
by a doctor - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by a nurse – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
c. No. of deliveries attended
by midwives - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
22. No. of deliveries attended by
non-skilled health
professionals - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
a. No. of deliveries attended
by Hilot/TBA - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of deliveries attended
by others - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
23. No. of health facility-based
deliveries - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
27c. No. of fetal deaths - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
27d. No. of abortion/
miscarriage - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0

Section C. Child Care a

Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
C1. Immunization Services
1. CPAB - Total 0 0 0 6. DPT-HiB-HepB 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
2. BCG - Total 0 0 0 7. OPV 1 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
3. HepB, within 24 hours. - Total 0 0 0 8. OPV 2 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
4. DPT-HiB-HepB 1 - Total 0 0 0 9. OPV 3 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
5. DPT-HiB-HepB 2 - Total 0 0 0 10. IPV - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
16. FIC - Total 0 0 0 18. Td, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
17. CIC - Total 0 0 0 19. MR, Grade 1 (November) - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
C2. Nutrition Services
22. Newborns initiated on breastfeeding
immediately after birth lasting to 90 mins - 28. Infants 6-11 mos. old seen - Total
Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
23. Preterm/LBW infants given iron 29. Infants 6-11 mos. given 1 dose of
supplementation - Total 0 0 0 Vitamin A 100,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
24. Infants 6 mos. old seen - Total 0 0 0 30. Children 12-59 mos seen - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
25. Infants exclusively breastfed until 6th month - 31. Children 12-59 mos. old given 2
Total 0 0 0 doses of Vitamin A 200,000 I.U. - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
26. Infants 6 mos. old initiated to complementary 32. Infant 6-11 months old who completed
feeding with continued breastfeeding - Total 0 0 0 MNP supplementation - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
27. Infants 6 mos. old initiated to complementary
feeding but no longer or never been breastfed 33. Children 12-23 mos. seen - Total
- Total 0 0 0
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
0
40. 1-19 y/o given 2 doses of deworming drug - 42. SAC, 5-9 y/o dewormed (2 doses) -
Total 0 0 0 Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
41. PSAC, 1-4 y/o dewormed (2 doses) - Total 0 0 0
• NHTS 0
• Non-NHTS 0
0
44. Sick Infants 6-11 mos. old seen - Total 47. Sick Children 12-59 mos. old
0 0 0 received Vitamin A - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
45. Sick Infants 6-11 mos. old received 48. Diarrhea cases 0-59 months old seen
Vitamin A - Total 0 0 0 - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
49. Diarrhea cases 0-59 months old
46. Sick Children 12-59 mos. old seen - Total
0 0 0 received ORS - Total
• NHTS 0 • NHTS
• Non-NHTS 0 • Non-NHTS
 To be submitted Qua
Section E. Infectious Disease Preven
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
E1. Filariasis Prevention and Control E2. Schistosomiasis Prevention and Contro
1. No. of individual examined for lymphatic 1. No. of people 5-65 y/o who ingested
filariasis - Total 0 MDA drugs - Total
2. No. of individual examined found positive for 2. No. of patients seen - Total
lymphatic filariasis - Total 0 3. No. of suspected cases seen
3. No. of lymphatic filariasis cases examined with 4. No. acute clinically diagnosed cases -
manifestation of either lymphedema,hydrocele, Total
elephantiasis - Total
0 5. No. of confirmed acute cases - Total
6. No. of chronic clinically diagnosed
cases - Total
Section F. _________________________
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
 ___JANUARY_____ YEAR: ____2020___

M1
AGPAKO__________________________
_________________________
_________________________

BRGY
________________________
________________________
r submission to RHU/MHC

Services and Deworming for Women of Reproductive Age

Total A3. Deworming Services SES Total

Col. 3) (Col. 1) (Col. 2) (Col. 3)

NHTS Non-NHTS
1. No. of women 20-49 years old given 2 doses of
15 deworming drugs - Total
0 0 0
15
0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 5 0 0 0 0 0 0 0
5 5 0
0 0 0
5 5 5 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
on B. Maternal Care and Services
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

a. Number of pregnant women seen in the

first trimester who have normal BMI -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
b. No. of pregnant women seen in the first
trimester who have low BMI - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

7. No. of pregnant women given iodine

capsules – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
8. No. of pregnant women given one dose
of deworming tablet - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
9. No. of pregnant women screened for
syphilis - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
10. No. of pregnant women tested positive
for syphilis - Total

0 0 0 0
 • NHTS 0
• Non-NHTS 0
11. No. of pregnant women screened for
Hepatitis B - Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
18. No. of deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
19. No. of live births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20a. No. of live births with normal birth
weight - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
20b. No. of live births with low birth weight
- Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
20c. No. of live births with unknown birth
weight- Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
21. No. of deliveries attended by skilled
health professionals - Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col 3)  (Col. 4)
rks Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

24a. No. of deliveries in public health

facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
24b. No. of deliveries in private health
facility - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
25. No. of non-facility-based deliveries -
Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
26a. No. of vaginal deliveries – Total

0 0 0 0
• NHTS 0
• Non-NHTS 0
26b. No. of deliveries by cesarean
section – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
27a. No. of full-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
27b. No. of pre-term births – Total
0 0 0 0
• NHTS 0
• Non-NHTS 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B3. Postpartum and Newborn Care
28. No. of postpartum women together
with their newborn who completed at
least 2 postpartum check-ups - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
 29. No. of postpartum women who
completed iron with folic acid
supplementation - Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
30. No. of postpartum women with
Vitamin A supplementation – Total 0 0 0 0
• NHTS 0
• Non-NHTS 0
ction C. Child Care and Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)

epB 3 - Total 0 0 0 11. PCV 1 - Total 0 0

0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 12. PCV 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 13. PCV 3 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
al 0 0 0 14. MMR 1 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
0 0 0 15. MMR 2 - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
1 (November) - Total 0 0 0 20. Td, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
e 1 (November) - Total 0 0 0 21. MR, Grade 7 (November) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

34. Children 12-23 mos. who completed

1 mos. old seen - Total
MNP supplementation - Total
0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
 1 mos. given 1 dose of
35. Children 0-59 mos. seen - Total
100,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos seen - Total 0 0 0 36. Stunted - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
2-59 mos. old given 2
37. Wasted - Total
tamin A 200,000 I.U. - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
1 months old who completed
38. Overweight/Obese - Total
lementation - Total 0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS

2-23 mos. seen - Total 39. Normal - Total

0 0 0 0 0
0 • NHTS
TS 0 • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col. 1) (Col 2) (Col 3)

y/o dewormed (2 doses) - 43. Adolescents, 10-19 y/o dewormed

0 0 0 (2 doses) - Total 0 0
0 • NHTS
TS 0 • Non-NHTS

ren 12-59 mos. old 50. Diarrhea cases 0-59 mos. received
itamin A - Total 0 0 0 ORS w/ zinc - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old seen 51. Pneumonia cases 0-59 mos. old
0 0 0 seen - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
ases 0-59 months old 52. Pneumonia cases 0-59 mos. old
ORS - Total 0 0 0 completed treatment - Total 0 0
0 • NHTS
TS 0 • Non-NHTS
 To be submitted Quarterly
ous Disease Prevention and Control Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
miasis Prevention and Control E2. Schistosomiasis Prevention and Control (Con't.)
le 5-65 y/o who ingested 7. No. confirmed chronic cases - Total
- Total 0
nts seen - Total 0 8. No. of confirmed cases (acute and
ected cases seen 0 chronic) - Total
clinically diagnosed cases - 9. No. of cases treated - Total
0
rmed acute cases - Total 0 10. No. of confirmed chronic cases
nic clinically diagnosed referred to a hospital facility - Total
al 0
_________________________________________
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
M1
RGY
Total

(Col. 3)

New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
 0 0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0
0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
0 0
0
0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0 0
0
0
0 0
0
0
0 0
0
0
 0 0
0
0

Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
 Total
(Col 4)

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Total
(Col 4)
0
0
0
0
0
0

0
0
0
 0
0
0
0
0
0

0
0
0

0
0
0

0
0
0
Total
(Col 4)

0
0
0

0
0
0

0
0
0

0
0
0
 Total
(Col 4)
't.)

Total
(Col 4)
 FHSIS REPORT for the MONTH: ________ YEAR:
Name of Barangay: _______________________
Name of BHS: _______________________
Name of Municipality/City: _______________________
Name of Province: ________________________
Projected Population of the Year: _______________________
For submission to RHU/MHC

Section A. Family Planning Services and Dewor

A1. Modern FP Unmet Need Age Total

(Col. 1) (Col. 2) (Col. 3)

10-14 15-19 20-49
1. No. of WRA with unmet
need for modern FP - Total 395 410 415
1220
• NHTS 395 400 400 1195
• Non-NHTS 0 10 15 25
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
a. Female Sterilization/ BTL - 20 0 33 53 5 0 0 5 5
Total
• NHTS 0 0 3 3 0 0 0 0 0
• Non-NHTS 20 0 30 50 5 0 0 5 5
b. Male Sterilization/ NSV-Total 0 0 1 1 0 0 0 0 0
• NHTS 0 0 0 0 0 0 0 0 0
• Non-NHTS 0 0 1 1 0 0 0 0 0
c. Condom - Total 0 0 25 25 0 0 0 0 0
• NHTS 0 0 2 2 0 0 0 0 0
• Non-NHTS 0 0 23 23 0 0 0 0 0
d. Pills - Total 0 22 241 263 0 2 0 2 0
• NHTS 0 2 39 41 0 0 0 0 0
• Non-NHTS 0 18 203 221 0 0 0 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
 d.1 Pills-POP - Total 0 4 10 14 0 0 91 91 0
• NHTS 0 0 0 0 0 0 56 56 0
• Non-NHTS 0 2 10 12 0 0 35 35 0
d.2 Pills-COC - Total 0 18 228 246 0 0 21 21 0
• NHTS 0 2 37 39 0 0 14 14 0
• Non-NHTS 0 16 191 207 0 0 7 7 0
e. Injectables (DMPA/ POI) - 0 5 29 34 0 0 7 7 0
Total
• NHTS 0 1 4 5 0 0 0 0 0
• Non-NHTS 0 4 25 29 0 0 0 0 0
f. Implant - Total 0 0 4 4 0 0 0 0 0
• NHTS 0 0 0 0 0 0 0 0 0
• Non-NHTS 0 0 4 4 0 0 0 0 0
g. IUD (IUD-I and IUD-PP) - 0 0 21 21 0 0 0 0 0
Total
• NHTS 0 0 4 4 0 0 0 0 0
• Non-NHTS 0 0 17 17 0 0 0 0 0
g.1 IUD-I- Total 0 0 20 20 0 0 0 0 0
• NHTS 0 0 4 4 0 0 0 0 0
• Non-NHTS 0 0 16 16 0 0 0 0 0
g.2 IUD-PP - Total 0 0 1 1 0 0 0 0 0
• NHTS 0 0 0 0 0 0 0 0 0
• Non-NHTS 0 0 1 1 0 0 0 0 0
h. NFP-LAM - Total 0 3 7 10 0 1 0 1 0
• NHTS 0 1 1 2 0 0 0 0 0
• Non-NHTS 0 2 6 8 0 1 0 1 0
i. NFP-BBT - Total 0 0 0 0 0 0 0 0 0
• NHTS 0 0 0 0 0 0 0 0 0
• Non-NHTS 0 0 0 0 0 0 0 0 0
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
j. NFP-CMM - Total 0 0 75 75 0 0 0 0 0
• NHTS 0 0 3 3 0 0 0 0 0
• Non-NHTS 0 0 72 72 0 0 0 0 0
k. NFP-STM - Total 0 0 23 23 0 0 0 0 0
• NHTS 0 0 0 0 0 0 0 0 0
• Non-NHTS 0 0 23 23 0 0 0 0 0
l. NFP-SDM - Total 0 0 125 125 0 0 0 0 0
• NHTS 0 0 10 10 0 0 0 0 0
• Non-NHTS 0 0 115 115 0 0 0 0 0
m. Total Current Users 0 37 523 560 0 0 0 0 0
• NHTS 0 7 57 64 0 0 0 0 0
• Non-NHTS 0 30 466 496 0 0 0 0 0
Section B. Maternal Care
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
1. No. of pregnant women w/
at least 4 prenatal check- 0 1 3
ups - Total 12
• NHTS 0 0 0 0
• Non-NHTS 0 1 3 12
2. No. of pregnant women
assessed of their nutritional 0 1 3
status during the 1st tri. -Total 12
• NHTS 0 0 0 0
• Non-NHTS 0 1 3 12
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
c. No. of pregnant women
seen in the first trimester 0 0 0
who have high BMI - Total 0
• NHTS 0 0 0 0
• Non-NHTS 0 0 0 0
3. No. of pregnant women for
the first time given 2 doses of 0 1 0
Td vaccination - Total 3
• NHTS 0 0 0 0
• Non-NHTS 0 1 0 3
4. No. of pregnant women for
the 2nd or more times given
0 0 3
at least 3 doses of Td
vaccination (Td2 Plus) - Total 9
• NHTS 0 0 0 0
• Non-NHTS 0 0 3 9
5. No. of pregnant women who
completed the dose of iron
0 1 3
with folic acid
supplementation - Total 12
 • NHTS 0 0 0 0
• Non-NHTS 0 1 3 12
6. No. of pregnant women who
completed doses of calcium
0 0 0
carbonate supplementation -
Total 0
• NHTS 0 0 0 0
• Non-NHTS 0 0 0 0
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
12. No. of pregnant women
tested positive for Hepatitis 0 0 0
B - Total 0
• NHTS 0 0 0 0
• Non-NHTS 0 0 0 0
13. No. of pregnant women
0 0 0
screened for HIV - Total 0
• NHTS 0 0 0 0
• Non-NHTS 0 0 0 0
14. No. of pregnant women
tested for CBC or Hgb&Hct 0 1 0
count - Total 3
• NHTS 0 0 0 0
• Non-NHTS 0 1 0 3
15. No. of pregnant women
tested for CBC or Hgb&Hct
0 0 0
count diagnosed with
anemia - Total 0
• NHTS 0 0 0 0
• Non-NHTS 0 0 0 0
16. No. of pregnant women
screened for gestational 0 0 0
diabetes – Total 0
• NHTS 0 0 0 0
• Non-NHTS 0 0 0 0
17.   No. of pregnant women
tested positive for 0 0 0
gestational diabetes – Total 0
• NHTS 0 0 0 0
• Non-NHTS 0 0 0 0
Indicators Age Total Remarks
(Col 3)  (Col. 4)
 Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
a. No. of deliveries attended
0 0 3
by a doctor - Total 9
• NHTS 0 0 0 0
• Non-NHTS 0 0 3 9
b. No. of deliveries attended
0 0 0
by a nurse – Total 0
• NHTS 0 0 0 0
• Non-NHTS 0 0 0 0
c. No. of deliveries attended
0 1 0
by midwives - Total 3
• NHTS 0 0 0 0
• Non-NHTS 0 1 0 3
22. No. of deliveries attended by
non-skilled health 0 0 0
professionals - Total 0
• NHTS 0 0 0 0
• Non-NHTS 0 0 0 0
a. No. of deliveries attended
0 0 0
by Hilot/TBA - Total 0
• NHTS 0 0 0 0
• Non-NHTS 0 0 0 0
b. No. of deliveries attended
0 0 0
by others - Total 0
• NHTS 0 0 0 0
• Non-NHTS 0 0 0 0
23. No. of health facility-based
0 0 3
deliveries - Total 9
• NHTS 0 0 0 0
• Non-NHTS 0 0 3 9
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
27c. No. of fetal deaths - Total
0 0 0

• NHTS 0 0 0
• Non-NHTS 0 0 0
27d. No. of abortion/
0 0 0
miscarriage - Total

• NHTS 0 0 0
• Non-NHTS 0 0 0

Section C. Child Care a

Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
C1. Immunization Services
1. CPAB - Total 1 4 15 6. DPT-HiB-HepB 3 - Total
• NHTS 0 0 0 • NHTS
• Non-NHTS 1 4 15 • Non-NHTS
2. BCG - Total 1 4 15 7. OPV 1 - Total
• NHTS 0 0 0 • NHTS
• Non-NHTS 1 4 15 • Non-NHTS
3. HepB, within 24 hours. - Total 1 4 15 8. OPV 2 - Total
• NHTS 0 0 0 • NHTS
• Non-NHTS 1 2 9 • Non-NHTS
4. DPT-HiB-HepB 1 - Total 1 1 6 9. OPV 3 - Total
• NHTS 0 0 0 • NHTS
• Non-NHTS 1 1 6 • Non-NHTS
5. DPT-HiB-HepB 2 - Total 2 2 12 10. IPV - Total
• NHTS 0 0 0 • NHTS
• Non-NHTS 2 2 12 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
16. FIC - Total 1 5 18 18. Td, Grade 1 (November) - Total
• NHTS 0 0 0 • NHTS
• Non-NHTS 1 5 18 • Non-NHTS
17. CIC - Total 0 0 0 19. MR, Grade 1 (November) - Total
• NHTS 0 0 0 • NHTS
• Non-NHTS 0 0 0 • Non-NHTS
C2. Nutrition Services
22. Newborns initiated on breastfeeding
immediately after birth lasting to 90 mins - 28. Infants 6-11 mos. old seen - Total
Total 1 3 12
• NHTS 0 0 0 • NHTS
• Non-NHTS 0 1 3 • Non-NHTS
23. Preterm/LBW infants given iron 29. Infants 6-11 mos. given 1 dose of
supplementation - Total 0 0 0 Vitamin A 100,000 I.U. - Total
• NHTS 0 0 0 • NHTS
• Non-NHTS 0 0 0 • Non-NHTS
24. Infants 6 mos. old seen - Total 4 5 27 30. Children 12-59 mos seen - Total
• NHTS 0 0 0 • NHTS
• Non-NHTS 1 0 3 • Non-NHTS
25. Infants exclusively breastfed until 6th month - 31. Children 12-59 mos. old given 2
Total 4 5 27 doses of Vitamin A 200,000 I.U. - Total
• NHTS 0 0 0 • NHTS
• Non-NHTS 1 0 3 • Non-NHTS
26. Infants 6 mos. old initiated to complementary 32. Infant 6-11 months old who completed
feeding with continued breastfeeding - Total 1 0 3 MNP supplementation - Total
• NHTS 0 0 0 • NHTS
• Non-NHTS 1 0 3 • Non-NHTS
27. Infants 6 mos. old initiated to complementary
feeding but no longer or never been breastfed 33. Children 12-23 mos. seen - Total
- Total 1 0 3
• NHTS 0 0 0 • NHTS
• Non-NHTS 1 0 3 • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
C3. Deworming Services
40. 1-19 y/o given 2 doses of deworming drug - 42. SAC, 5-9 y/o dewormed (2 doses) -
Total 0 0 0 Total
• NHTS 0 0 0 • NHTS
• Non-NHTS 0 0 0 • Non-NHTS
41. PSAC, 1-4 y/o dewormed (2 doses) - Total 0 0 0
• NHTS 0 0 0
• Non-NHTS 0 0 0
C4. Management of Sick Infants and Children
44. Sick Infants 6-11 mos. old seen - Total 47. Sick Children 12-59 mos. old
0 0 0 received Vitamin A - Total
• NHTS 0 0 0 • NHTS
• Non-NHTS 0 0 0 • Non-NHTS
45. Sick Infants 6-11 mos. old received 48. Diarrhea cases 0-59 months old seen
Vitamin A - Total 0 0 0 - Total
• NHTS 0 0 0 • NHTS
• Non-NHTS 0 0 0 • Non-NHTS
49. Diarrhea cases 0-59 months old
46. Sick Children 12-59 mos. old seen - Total
0 0 0 received ORS - Total
• NHTS 0 0 0 • NHTS
• Non-NHTS 0 0 0 • Non-NHTS
 Section D. Oral Care a
To be submitted Qua
Section E. Infectious Disease Preven
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
E1. Filariasis Prevention and Control E2. Schistosomiasis Prevention and Contro
1. No. of individual examined for lymphatic 1. No. of people 5-65 y/o who ingested
filariasis - Total 0 0 MDA drugs - Total
2. No. of individual examined found positive for 0 0 2. No. of patients seen - Total
lymphatic filariasis - Total 0 0 3. No. of suspected cases seen
3. No. of lymphatic filariasis cases examined with 4. No. acute clinically diagnosed cases -
manifestation of either lymphedema,hydrocele, 0 0 Total
elephantiasis - Total
0 0 5. No. of confirmed acute cases - Total
6. No. of chronic clinically diagnosed
cases - Total
Section F. _________________________
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
 ________ YEAR: _______

M1
________________________
_________________________
_________________________

BRGY
________________________
________________________
r submission to RHU/MHC

Services and Deworming for Women of Reproductive Age

Total A3. Deworming Services SES Total

Col. 3) (Col. 1) (Col. 2) (Col. 3)

NHTS Non-NHTS
1. No. of women 20-49 years old given 2 doses of 0 0
1220 deworming drugs - Total
1195
25
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 5 5 0 2 7 0 0 31 31 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 5 5 0 0 5 0 0 4 4 0 0
0 0 0 0 0 1 1 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 1 1 0 0 0 0 0 0
0 0 0 0 0 20 20 0 0 5 5 0 0
0 0 0 0 0 2 2 0 0 2 2 0 0
0 0 0 0 0 18 18 0 0 3 3 0 0
0 0 0 0 0 15 15 0 20 226 246 0 0
0 0 0 0 0 5 5 0 2 34 36 0 0
0 0 0 0 0 10 10 0 18 192 210 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
 0 260 260 0 0 0 0 0 4 10 14 0 0
0 160 160 0 0 0 0 0 0 0 0 0 0
0 100 100 0 0 0 0 0 2 10 12 0 0
0 60 60 0 2 83 85 0 16 145 161 0 0
0 40 40 0 0 20 20 0 2 17 19 0 0
0 20 20 0 0 63 63 0 14 128 142 0 0
0 20 20 0 0 0 0 0 5 56 61 0 0

0 0 0 0 0 0 0 0 1 5 6 0 0
0 0 0 0 0 0 0 0 4 51 55 0 0
0 0 0 0 0 1 1 0 0 3 3 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 1 1 0 0 3 3 0 0
0 0 0 0 0 4 4 0 0 17 17 0 0

0 0 0 0 0 0 0 0 0 4 4 0 0
0 0 0 0 0 4 4 0 0 17 17 0 0
0 0 0 0 0 0 0 0 0 20 20 0 0
0 0 0 0 0 0 0 0 0 4 4 0 0
0 0 0 0 0 0 0 0 0 16 16 0 0
0 0 0 0 0 0 0 0 0 1 1 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 1 1 0 0
0 11 11 0 0 0 0 0 3 18 21 0 1
0 5 5 0 0 0 0 0 0 2 2 0 0
0 6 6 0 0 0 0 0 3 16 19 0 1
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
0 0 0 0 385 10 395 0 1888 65 1953 0 0
0 0 0 0 238 3 241 0 1167 3 1170 0 0
0 0 0 0 147 7 154 0 721 62 783 0 0
0 0 0 0 91 5 96 0 446 18 464 0 0
0 0 0 0 56 0 56 0 275 0 275 0 0
0 0 0 0 35 5 40 0 171 18 189 0 0
0 0 0 0 21 20 41 0 104 105 209 0 0
0 0 0 0 14 3 17 0 67 7 74 0 0
0 0 0 0 7 17 24 0 37 98 135 0 0
 0 0 0 0 7 20 27 0 30 503 533 0 0
0 0 0 0 0 0 0 0 7 20 27 0 0
0 0 0 0 0 0 0 0 23 483 506 0 0
on B. Maternal Care and Services
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

a. Number of pregnant women seen in the

first trimester who have normal BMI -
Total 0 1 3 12
• NHTS 0 0 0 0
• Non-NHTS 0 1 3 12
b. No. of pregnant women seen in the first
trimester who have low BMI - Total
0 0 0 0
• NHTS 0 0 0 0
• Non-NHTS 0 0 0 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

7. No. of pregnant women given iodine

capsules – Total
0 0 0 0
• NHTS 0 0 0 0
• Non-NHTS 0 0 0 0
8. No. of pregnant women given one dose
of deworming tablet - Total
0 0 0 0
• NHTS 0 0 0 0
• Non-NHTS 0 0 0 0
9. No. of pregnant women screened for
syphilis - Total

0 0 0 0
• NHTS 0 0 0 0
• Non-NHTS 0 0 0 0
10. No. of pregnant women tested positive
for syphilis - Total

0 0 0 0
 • NHTS 0 0 0 0
• Non-NHTS 0 0 0 0
11. No. of pregnant women screened for
Hepatitis B - Total

0 0 3 9
• NHTS 0 0 0 0
• Non-NHTS 0 0 3 9
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
18. No. of deliveries – Total

0 1 0 9
• NHTS 0 0 0 0
• Non-NHTS 0 1 0 9
19. No. of live births – Total
0 1 0 0
• NHTS 0 0 0 0
• Non-NHTS 0 1 0 0
20a. No. of live births with normal birth
weight - Total
0 1 0 3
• NHTS 0 0 0 0
• Non-NHTS 0 1 0 3
20b. No. of live births with low birth weight
- Total

0 0 0 12
• NHTS 0 0 0 0
• Non-NHTS 0 0 0 12
20c. No. of live births with unknown birth
weight- Total
0 0 0 0
• NHTS 0 0 0 0
• Non-NHTS 0 0 0 0
21. No. of deliveries attended by skilled
health professionals - Total
0 1 0 12
• NHTS 0 0 0 0
• Non-NHTS 0 1 0 12
rks Indicators Age Total Remarks
4) (Col 3)  (Col. 4)
rks Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

24a. No. of deliveries in public health

facility - Total 0 0 3 9
• NHTS 0 0 0 0
• Non-NHTS 0 0 3 9
24b. No. of deliveries in private health
facility - Total 0 0 0 0
• NHTS 0 0 0 0
• Non-NHTS 0 0 0 0
25. No. of non-facility-based deliveries -
Total 0 1 0 3
• NHTS 0 0 0 0
• Non-NHTS 0 1 0 3
26a. No. of vaginal deliveries – Total

0 1 3 12
• NHTS 0 0 0 0
• Non-NHTS 0 1 3 12
26b. No. of deliveries by cesarean
section – Total 0 0 0 0
• NHTS 0 0 0 0
• Non-NHTS 0 0 0 0
27a. No. of full-term births – Total
0 1 3 12
• NHTS 0 0 0 0
• Non-NHTS 0 1 3 12
27b. No. of pre-term births – Total
0 0 0 0
• NHTS 0 0 0 0
• Non-NHTS 0 0 0 0
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B3. Postpartum and Newborn Care
28. No. of postpartum women together
with their newborn who completed at
least 2 postpartum check-ups - Total 0 1 3 12
• NHTS 0 0 0 0
• Non-NHTS 0 1 3 12
 29. No. of postpartum women who
completed iron with folic acid
supplementation - Total 0 1 3 12
• NHTS 0 0 0 0
• Non-NHTS 0 1 3 12
30. No. of postpartum women with
Vitamin A supplementation – Total 0 0 0 0
• NHTS 0 0 0 0
• Non-NHTS 0 0 0 0
ction C. Child Care and Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)

epB 3 - Total 2 3 15 11. PCV 1 - Total 1 1

0 0 0 • NHTS 0 0
TS 2 3 15 • Non-NHTS 1 1
al 1 1 6 12. PCV 2 - Total 2 2
0 0 0 • NHTS 0 0
TS 1 1 6 • Non-NHTS 2 2
al 2 2 12 13. PCV 3 - Total 2 3
0 0 0 • NHTS 0 0
TS 2 2 12 • Non-NHTS 2 3
al 2 3 15 14. MMR 1 - Total 1 5
0 0 0 • NHTS 0 2
TS 2 3 15 • Non-NHTS 1 3
2 3 15 15. MMR 2 - Total 4 2
0 0 0 • NHTS 0 0
TS 2 3 15 • Non-NHTS 4 2
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
1 (November) - Total 0 0 0 20. Td, Grade 7 (November) - Total 0 0
0 0 0 • NHTS 0 0
TS 0 0 0 • Non-NHTS 0 0
e 1 (November) - Total 0 0 0 21. MR, Grade 7 (November) - Total 0 0
0 0 0 • NHTS 0 0
TS 0 0 0 • Non-NHTS 0 0

34. Children 12-23 mos. who completed

1 mos. old seen - Total
MNP supplementation - Total
0 0 0 0 0
0 0 0 • NHTS 0 0
TS 0 0 0 • Non-NHTS 0 0
 1 mos. given 1 dose of
35. Children 0-59 mos. seen - Total
100,000 I.U. - Total 0 0 0 0 0
0 0 0 • NHTS 0 0
TS 0 0 0 • Non-NHTS 0 0
2-59 mos seen - Total 0 0 0 36. Stunted - Total 0 0
0 0 0 • NHTS 0 0
TS 0 0 0 • Non-NHTS 0 0
2-59 mos. old given 2
37. Wasted - Total
tamin A 200,000 I.U. - Total 0 0 0 0 0
0 0 0 • NHTS 0 0
TS 0 0 0 • Non-NHTS 0 0
1 months old who completed
38. Overweight/Obese - Total
lementation - Total 0 0 0 0 0
0 0 0 • NHTS 0 0
TS 0 0 0 • Non-NHTS 0 0

2-23 mos. seen - Total 39. Normal - Total

0 0 0 0
0 0 • NHTS 0 0
TS 0 0 • Non-NHTS 0 0
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)

y/o dewormed (2 doses) - 43. Adolescents, 10-19 y/o dewormed

0 0 0 (2 doses) - Total 0 0
0 0 0 • NHTS 0 0
TS 0 0 0 • Non-NHTS 0 0

ren 12-59 mos. old 50. Diarrhea cases 0-59 mos. received
itamin A - Total 0 0 0 ORS w/ zinc - Total 0 0
0 0 0 • NHTS 0 0
TS 0 0 0 • Non-NHTS 0 0
ases 0-59 months old seen 51. Pneumonia cases 0-59 mos. old
0 0 0 seen - Total 0 0
0 0 0 • NHTS 0 0
TS 0 0 0 • Non-NHTS 0 0
ases 0-59 months old 52. Pneumonia cases 0-59 mos. old
ORS - Total 0 0 0 completed treatment - Total 0 0
0 0 0 • NHTS 0 0
TS 0 0 0 • Non-NHTS 0 0
ction D. Oral Care and Services
To be submitted Quarterly
ous Disease Prevention and Control Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
miasis Prevention and Control E2. Schistosomiasis Prevention and Control (Con't.)
le 5-65 y/o who ingested 7. No. confirmed chronic cases - Total
0 0
- Total 0 0
nts seen - Total 0 0 8. No. of confirmed cases (acute and 0 0
ected cases seen 0 0 chronic) - Total
clinically diagnosed cases - 9. No. of cases treated - Total
0 0
0 0
rmed acute cases - Total 0 0 10. No. of confirmed chronic cases
nic clinically diagnosed referred to a hospital facility - Total
al 0 0
_________________________________________
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
M1
RGY
Total

(Col. 3)

New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0 0

0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
4 4
0 0
4 4
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
 2 2
0 0
0 0
2 2
0 0
0 0
0 0

0 0
0 0
0 0
0 0
0 0
0 0

0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 1
0 0
0 1
0 0
0 0
0 0
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
 0 0
0 0
0 0

Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
 Total
(Col 4)

6
0
6
12
0
12
15
0
15
18
6
12
18
0
18
Total
(Col 4)
0
0
0
0
0
0

0
0
0
 0
0
0
0
0
0

0
0
0

0
0
0

0
0
0
Total
(Col 4)

0
0
0

0
0
0

0
0
0

0
0
0
 Total
(Col 4)
't.)

Total
(Col 4)
 FHSIS REPORT for the MONTH: ________ YEAR:
Name of Barangay: _______________________
Name of BHS: _______________________
Name of Municipality/City: _______________________
Name of Province: ________________________
Projected Population of the Year: _______________________
For submission to RHU/MHC

Section A. Family Planning Services and Dewor

A1. Modern FP Unmet Need Age Total

(Col. 1) (Col. 2) (Col. 3)

10-14 15-19 20-49
1. No. of WRA with unmet
need for modern FP - Total
• NHTS
• Non-NHTS
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
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
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
 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
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
A2. Use of FP Method Current User Acceptors
(Beginning Month) New Acceptors Other Acceptors
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14
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
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
1. No. of pregnant women w/
at least 4 prenatal check-
ups - Total
• NHTS
• Non-NHTS
2. No. of pregnant women
assessed of their nutritional
status during the 1st tri. -Total
• NHTS
• Non-NHTS
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
c. No. of pregnant women
seen in the first trimester
who have high BMI - Total
• NHTS
• Non-NHTS
3. No. of pregnant women for
the first time given 2 doses of
Td vaccination - Total
• NHTS
• Non-NHTS
4. No. of pregnant women for
the 2nd or more times given
at least 3 doses of Td
vaccination (Td2 Plus) - Total
• NHTS
• Non-NHTS
5. No. of pregnant women who
completed the dose of iron
with folic acid
supplementation - Total
 • NHTS
• Non-NHTS
6. No. of pregnant women who
completed doses of calcium
carbonate supplementation -
Total
• NHTS
• Non-NHTS
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B1. Prenatal Care
12. No. of pregnant women
tested positive for Hepatitis
B - Total
• NHTS
• Non-NHTS
13. No. of pregnant women
screened for HIV - Total
• NHTS
• Non-NHTS
14. No. of pregnant women
tested for CBC or Hgb&Hct
count - Total
• NHTS
• Non-NHTS
15. No. of pregnant women
tested for CBC or Hgb&Hct
count diagnosed with
anemia - Total
• NHTS
• Non-NHTS
16. No. of pregnant women
screened for gestational
diabetes – Total
• NHTS
• Non-NHTS
17.   No. of pregnant women
tested positive for
gestational diabetes – Total
• NHTS
• Non-NHTS
Indicators Age Total Remarks
(Col 3)  (Col. 4)
 Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
a. No. of deliveries attended
by a doctor - Total
• NHTS
• Non-NHTS
b. No. of deliveries attended
by a nurse – Total
• NHTS
• Non-NHTS
c. No. of deliveries attended
by midwives - Total
• NHTS
• Non-NHTS
22. No. of deliveries attended by
non-skilled health
professionals - Total
• NHTS
• Non-NHTS
a. No. of deliveries attended
by Hilot/TBA - Total
• NHTS
• Non-NHTS
b. No. of deliveries attended
by others - Total
• NHTS
• Non-NHTS
23. No. of health facility-based
deliveries - Total
• NHTS
• Non-NHTS
Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
27c. No. of fetal deaths - Total

• NHTS
• Non-NHTS
27d. No. of abortion/
miscarriage - Total

• NHTS
• Non-NHTS

Section C. Child Care a

Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
C1. Immunization Services
1. CPAB - Total 6. DPT-HiB-HepB 3 - Total
• NHTS • NHTS
• Non-NHTS • Non-NHTS
2. BCG - Total 7. OPV 1 - Total
• NHTS • NHTS
• Non-NHTS • Non-NHTS
3. HepB, within 24 hours. - Total 8. OPV 2 - Total
• NHTS • NHTS
• Non-NHTS • Non-NHTS
4. DPT-HiB-HepB 1 - Total 9. OPV 3 - Total
• NHTS • NHTS
• Non-NHTS • Non-NHTS
5. DPT-HiB-HepB 2 - Total 10. IPV - Total
• NHTS • NHTS
• Non-NHTS • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
16. FIC - Total 18. Td, Grade 1 (November) - Total
• NHTS • NHTS
• Non-NHTS • Non-NHTS
17. CIC - Total 19. MR, Grade 1 (November) - Total
• NHTS • NHTS
• Non-NHTS • Non-NHTS
C2. Nutrition Services
22. Newborns initiated on breastfeeding
immediately after birth lasting to 90 mins - 28. Infants 6-11 mos. old seen - Total
Total
• NHTS • NHTS
• Non-NHTS • Non-NHTS
23. Preterm/LBW infants given iron 29. Infants 6-11 mos. given 1 dose of
supplementation - Total Vitamin A 100,000 I.U. - Total
• NHTS • NHTS
• Non-NHTS • Non-NHTS
24. Infants 6 mos. old seen - Total 30. Children 12-59 mos seen - Total
• NHTS • NHTS
• Non-NHTS • Non-NHTS
25. Infants exclusively breastfed until 6th month - 31. Children 12-59 mos. old given 2
Total doses of Vitamin A 200,000 I.U. - Total
• NHTS • NHTS
• Non-NHTS • Non-NHTS
26. Infants 6 mos. old initiated to complementary 32. Infant 6-11 months old who completed
feeding with continued breastfeeding - Total MNP supplementation - Total
• NHTS • NHTS
• Non-NHTS • Non-NHTS
27. Infants 6 mos. old initiated to complementary
feeding but no longer or never been breastfed 33. Children 12-23 mos. seen - Total
- Total
• NHTS • NHTS
• Non-NHTS • Non-NHTS
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
C3. Deworming Services
40. 1-19 y/o given 2 doses of deworming drug - 42. SAC, 5-9 y/o dewormed (2 doses) -
Total Total
• NHTS • NHTS
• Non-NHTS • Non-NHTS
41. PSAC, 1-4 y/o dewormed (2 doses) - Total
• NHTS
• Non-NHTS
C4. Management of Sick Infants and Children
44. Sick Infants 6-11 mos. old seen - Total 47. Sick Children 12-59 mos. old
received Vitamin A - Total
• NHTS • NHTS
• Non-NHTS • Non-NHTS
45. Sick Infants 6-11 mos. old received 48. Diarrhea cases 0-59 months old seen
Vitamin A - Total - Total
• NHTS • NHTS
• Non-NHTS • Non-NHTS
49. Diarrhea cases 0-59 months old
46. Sick Children 12-59 mos. old seen - Total
received ORS - Total
• NHTS • NHTS
• Non-NHTS • Non-NHTS
 Section D. Oral Care a
To be submitted Qua
Section E. Infectious Disease Preven
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
E1. Filariasis Prevention and Control E2. Schistosomiasis Prevention and Contro
1. No. of individual examined for lymphatic 1. No. of people 5-65 y/o who ingested
filariasis - Total MDA drugs - Total
2. No. of individual examined found positive for 2. No. of patients seen - Total
lymphatic filariasis - Total 3. No. of suspected cases seen
3. No. of lymphatic filariasis cases examined with 4. No. acute clinically diagnosed cases -
manifestation of either lymphedema,hydrocele, Total
elephantiasis - Total
5. No. of confirmed acute cases - Total
6. No. of chronic clinically diagnosed
cases - Total
Section F. _________________________
Indicators Male Female Total Indicators
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1)
 ________ YEAR: _______

M1
________________________
_________________________
_________________________

BRGY
________________________
________________________
r submission to RHU/MHC

Services and Deworming for Women of Reproductive Age

Total A3. Deworming Services SES Total

Col. 3) (Col. 1) (Col. 2) (Col. 3)

NHTS Non-NHTS
1. No. of women 20-49 years old given 2 doses of
deworming drugs - Total

cceptors Dropout Current User New Acceptors

Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19

cceptors Dropout Current User New Acceptors

Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
cceptors Dropout Current User New Acceptors
Other Acceptors (Present Month) (End of Month) (Present Month)
(Present Month)
(Col. 4) (Col. 5) (Col. 6) (Col. 7)
15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19
on B. Maternal Care and Services
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

a. Number of pregnant women seen in the

first trimester who have normal BMI -
Total
• NHTS
• Non-NHTS
b. No. of pregnant women seen in the first
trimester who have low BMI - Total

• NHTS
• Non-NHTS
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

7. No. of pregnant women given iodine

capsules – Total

• NHTS
• Non-NHTS
8. No. of pregnant women given one dose
of deworming tablet - Total

• NHTS
• Non-NHTS
9. No. of pregnant women screened for
syphilis - Total

• NHTS
• Non-NHTS
10. No. of pregnant women tested positive
for syphilis - Total
 • NHTS
• Non-NHTS
11. No. of pregnant women screened for
Hepatitis B - Total

• NHTS
• Non-NHTS
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B2. Intrapartum Care and Delivery Outcome
18. No. of deliveries – Total

• NHTS
• Non-NHTS
19. No. of live births – Total

• NHTS
• Non-NHTS
20a. No. of live births with normal birth
weight - Total

• NHTS
• Non-NHTS
20b. No. of live births with low birth weight
- Total

• NHTS
• Non-NHTS
20c. No. of live births with unknown birth
weight- Total

• NHTS
• Non-NHTS
21. No. of deliveries attended by skilled
health professionals - Total

• NHTS
• Non-NHTS
rks Indicators Age Total Remarks
4) (Col 3)  (Col. 4)
rks Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49

24a. No. of deliveries in public health

facility - Total
• NHTS
• Non-NHTS
24b. No. of deliveries in private health
facility - Total
• NHTS
• Non-NHTS
25. No. of non-facility-based deliveries -
Total
• NHTS
• Non-NHTS
26a. No. of vaginal deliveries – Total

• NHTS
• Non-NHTS
26b. No. of deliveries by cesarean
section – Total
• NHTS
• Non-NHTS
27a. No. of full-term births – Total

• NHTS
• Non-NHTS
27b. No. of pre-term births – Total

• NHTS
• Non-NHTS
rks Indicators Age Total Remarks
4) (Col. 1) (Col. 2) (Col 3)  (Col. 4)
 10-14   15-19 20-49
B3. Postpartum and Newborn Care
28. No. of postpartum women together
with their newborn who completed at
least 2 postpartum check-ups - Total
• NHTS
• Non-NHTS
 29. No. of postpartum women who
completed iron with folic acid
supplementation - Total
• NHTS
• Non-NHTS
30. No. of postpartum women with
Vitamin A supplementation – Total
• NHTS
• Non-NHTS
ction C. Child Care and Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)

epB 3 - Total 11. PCV 1 - Total

• NHTS
TS • Non-NHTS
al 12. PCV 2 - Total
• NHTS
TS • Non-NHTS
al 13. PCV 3 - Total
• NHTS
TS • Non-NHTS
al 14. MMR 1 - Total
• NHTS
TS • Non-NHTS
15. MMR 2 - Total
• NHTS
TS • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
1 (November) - Total 20. Td, Grade 7 (November) - Total
• NHTS
TS • Non-NHTS
e 1 (November) - Total 21. MR, Grade 7 (November) - Total
• NHTS
TS • Non-NHTS

34. Children 12-23 mos. who completed

1 mos. old seen - Total
MNP supplementation - Total

• NHTS
TS • Non-NHTS
 1 mos. given 1 dose of
35. Children 0-59 mos. seen - Total
100,000 I.U. - Total
• NHTS
TS • Non-NHTS
2-59 mos seen - Total 36. Stunted - Total
• NHTS
TS • Non-NHTS
2-59 mos. old given 2
37. Wasted - Total
tamin A 200,000 I.U. - Total
• NHTS
TS • Non-NHTS
1 months old who completed
38. Overweight/Obese - Total
lementation - Total
• NHTS
TS • Non-NHTS

2-23 mos. seen - Total 39. Normal - Total

• NHTS
TS • Non-NHTS
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)

y/o dewormed (2 doses) - 43. Adolescents, 10-19 y/o dewormed

(2 doses) - Total
• NHTS
TS • Non-NHTS

ren 12-59 mos. old 50. Diarrhea cases 0-59 mos. received
itamin A - Total ORS w/ zinc - Total
• NHTS
TS • Non-NHTS
ases 0-59 months old seen 51. Pneumonia cases 0-59 mos. old
seen - Total
• NHTS
TS • Non-NHTS
ases 0-59 months old 52. Pneumonia cases 0-59 mos. old
ORS - Total completed treatment - Total
• NHTS
TS • Non-NHTS
ction D. Oral Care and Services
To be submitted Quarterly
ous Disease Prevention and Control Services
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
miasis Prevention and Control E2. Schistosomiasis Prevention and Control (Con't.)
le 5-65 y/o who ingested 7. No. confirmed chronic cases - Total
- Total
nts seen - Total 8. No. of confirmed cases (acute and
ected cases seen chronic) - Total
clinically diagnosed cases - 9. No. of cases treated - Total

rmed acute cases - Total 10. No. of confirmed chronic cases

nic clinically diagnosed referred to a hospital facility - Total
al
_________________________________________
Indicators Male Female Total Indicators Male Female
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3)
M1
RGY
Total

(Col. 3)

New Acceptors
(Present Month)

(Col. 7)
20-49 Total

New Acceptors
(Present Month)

(Col. 7)
20-49 Total
New Acceptors
(Present Month)

(Col. 7)
20-49 Total
Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
Remarks
(Col. 4)

Remarks
(Col. 4)
 Total
(Col 4)

Total
(Col 4)
 Total
(Col 4)
 Total
(Col 4)
't.)

Total
(Col 4)