Republic of the Philippines

Province of Isabela
Municipality of San Mateo
Barangay Old Centro 1

BHW MONTHLY REPORT

Name: _____________________________
Designation: _______________________
Month: ____________________________

I. PREGNANT WOMEN (Registered for the month only) “PAGBUBUNTIS”.

FSN NAME AGE HUSBAND GP LM EDC Date Adm.
P

II. DELIVERED FOR THE MONTH ONLY: “NANGANAK”

FSN NAME AGE HUSBAND NAME OF CHILD Date

III. DIARRHEA CASES (case findings for the month) : Please report weekly
FSN NAME AGE FAMILY HEAD Date Adm.

IV. TB SYMTOMATICS (Case finding for the month only: Sputum smear done)
FSN NAME AGE FAMILY HEAD Date Adm.

V. FAMILY PLANNING (New Acceptor, Restart, Change Method, Transferred-in) for the month only.
FSN NAME AGE METHOD ACCEPTED DATE

VI. IMMUNIZATION (Children 0-1 years old) for the nob=nth only. “PAGBABAKUNA”
FS NAME BIRTHDAY MOTHER DATE VACCINE GIVEN
N

VII. PATIENTS FOR THE MONTH

FSN NAME AGE COMPLAINTS Date
VIII.BLOOD PRESSURE FOR THE MONTH ONLY
FSN NAME AGE BP Date

IX. DOGBITES (Case finding for the month only) Please report weekly
FSN NAME AGE FAMILY Date

X. LEPROSY (Case finding for the month only) “KETONG”

FSN NAME AGE FAMILY Date

XI. DEATHS DURING THE MONTH

NAME AGE CAUSE OF DEATH DATE OF DEATH ATTENDED BY

OTHER HEALTH ACTIVITIES FOR THE MONTH

DATE ACTIVITIES

Submitted by:

__________________________________
BHW

Submitted by:

__________________________________
BHW

Noted by: Approved by:

__________________________________ __________________________________
Barangay Captain Municipal Health Officer