Republic of the Philippines

Province of Isabela
Municipality of Quezon
Barangay __________
-oo0oo-

BHW MONTHLY REPORT

DATE: ______________________________ Score ______________
I. PREGNANT WOMEN( Registered for the Month only) “PAGBUBUNTIS”
NAME AGE HUSBAND GP LMP DATE FSN

II. DELIVERED FOR THE MONTH ONLY “NANGANAK”

NAME AGE HUSBAND NAME OF DEL. DATE ATTENDED Del. DELIVERED
CHILD TYPE DEL. BY: at BY:

III. TB SYMPTOMATICS (Case finding for the month only, sputum smear done) Pls.survey your purok monthly.
NAME AGE FAMILY HEAD FSN DATE

IV. IMMUNIZATION (Fully Immunized Child 9-12 months old, for the month only) “PAGBABAKUNA”
NAME OF CHILD BIRTHDATE MOTHER FSN DATE

V. LEPROSY (Case finding for the month only) “KETONG” BRING PATIENT TO RHU
NAME AGE FAMILY HEAD DATE

VI. DOGBITE (pls survey your purok weekly)

NAME AGE DATE BITTEN

VII. DEATHS FOR THE MONTH ONLY ( in your purok only)

NAME AGE DATE OF DEATH CAUSE OF DEATH

VIII. FAMILY PLANNING

NAME AGE FAMILY PLANNING METHOD TYPE OF CLIENT

IX. DATE OF DUTY AND ACTIVITIES DONE AT CLINIC ASSIGNED

Submitted by: Checked by:

_________________________ __________________________
BHW RHM
Noted by: Approved by:
_________________________ ALPHA P. DULIG, M.D._____
Barangay Captain Rural Health Physician