FHSIS REPORT for the: MONTH : APRIL YEAR: 2022

Name of Health Facility: BHS- STA. TERESITA

Name of Barangay: STA. TERESITA
Name of Municipality/ City: DUMARAN
Name of Province: PALAWAN
Projected Population of the Year: ______________________
For submission to RHU
Section B. MATERNAL CARE and SERVICES
INDICATOR AGE
TOTAL Remarks
B1. Prenatal Care 10-15 15-19 20-49

1. No. of Pregnant women with 4 or more Prenatal visits

0 0 1 1
2. No. of Pregnant women assessed of their nutritional status during the
1st Tri -Total 0 0 1 1
a. No. of Pregnant women seen in the first trimester who have Normal
BMI 0 0 1 1
b. No. of Pregnant women seen in the first trimester who have Low BMI 0 0 0 0
c. No. of Pregnant women seen in the first trimester who have High
BMI 0 0 0 0
3. No. Pregnant women for the first time given at least 2 doses of Td
vaccination 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) 0 0 1 1
5. No. of Pregnant women who completed the dose of iron w/ folic acid
supplementation 0 0 0 0
6. No. of Pregnant women who completed doses of Calcium Carbonate
supplementation 0 0 0 0
7. No. of Pregnant women given iodine capsules 0 0 0 0
8. No. of Pregnant women given one dose of deworming tablet 0 0 0 0
9. No. of Pregnant women screened for syphilis 0 0 0 0
10. No. of Pregnant women tested positive for syphilis 0 0 0 0
11. No. of Pregnant women screened for Hepatitis B 0 0 0 0
12. No. of Pregnant women tested positive for Hepatitis B 0 0 0 0
13. No. of pregnant women screened for HIV 0 0 0 0
14. No. of Pregnant women tested for CBC or Hgb & Hct count 0 0 0 0
15. No. of Pregnant women tested for CBC or Hgb & Hct count
diagnosed with anemia 0 0 0 0
16. No of Pregnant women screened for gestational diabetes 0 0 0 0
17. No. of Pregnant women tested positive for gestational diabetes 0 0 0 0
B3. POST PARTUM AND NEWBORN CARE 10-15 15-19 20-49 TOTAL REMARKS
25. No of Postpartum women together with their newborn who completed
at least 2 postpartum check ups 0 0 1 1
26. No. of Postpartum women who completed iron with folic acid
supplementation 0 0 1 1
27. No. of Postpartum women with Vitamin A Supplementation 0 0 1 1
 C. CHILD CARE AND SERVICES
C1. Immunization Services for newborns, infants
Male Female Total NUTRITION SERVICES FIR INFANTS AND CHILDREN Male Female Total
and School Aged Children/ Adolescents

● CPAB (Child Protected 1 0 1

22. Newborn initiated on breastfeeding immediately after 1
at Birth) birth lasting to 90 mins 0 1

● BCG 3 0 3 23. Preterm/LBW infants given iron supplementation. 0 0 0

within 24 hrs 0 0 0 24. Infants exclusively breastfed until 6th month 2

2 4
● Hepa B1 25. Infants 6 mos. Old inititated complementary feeding
> 24 hrs. 0 0 0 2
with continued breastfeeding 2 4

26. Infants 6 mos. Old inititated to complementary

1 4 5 9 0
feeding but no longer or never been breastfed 0 0

● PENTA 2 4 2 6 27. Infant 6-11 mo, given 1 dose of vitamin A. 100,000 IU 0

0 0
28. Children 12-59 mos. Old given 2 doses of Vitamin A
3 2 3 5 0
200,000IU 0 0
29. Infants 6-11 months old who completed MNP
1 0 0 0 0
supplementation 0 0

● OPV 30. Children 12-23 months who completed MNP

2 0 0 0 0 0
supplementation 0

3 0 0 0 Deworming services for Infants, Children, Adolescents

● IPV 0 31. 1-19 years old given 2 doses of deworming drug 0 0
0 0 0

1 5 6 11 a. PSAC 1-4 y/o dewormed (2 doses) 0 0

0

● PCV 2 4 2 6 b. SAC, 5-9 y/o dewormed (2 doses) 0 0

0

3 3 2
5 c. Adolsescents, 10-19 y/o dewormed (2 doses) 0 0
0

MCV1 (AMV) 3 5 8 Management of Sick Infants, Children, Adolescents

● MCV
MCV2 (MMR) 0 1 1 32. Sick Children 6-11 months old seen 0
0 0

Fully Immunized Child (0-12 months) 0 1 1 33. Sick Children 6-11months old received Vitamin A 0 0 0

Completely Immunized Child (13-23 34. Sick Children 12-59 months seen 0
0 0
months) 35. Sick Children 12-59 months received Vitamin A 0
0 0 0 0 0

Td,Grade 1 (NOV) 0 0 0
36. Diarrhea cases 0-59 months old seen 0
0 0

MR. Grade 1 0 0 0
37. Diarrhea cases 0-59 months old received ORS 0
0 0
38. Diarrhea cases 0-59 months old received ORS with
Td, Grade 7 0
0 0 0 zinc 0 0

MR Grade 7 0 0 0
39. Pneumonia cases 0-59 months old seen 0
0 0
40.Pneumonia cases 0-59 months old completed 0
treatment 0 0

OTHER VACCINATION Male Female Total

Flu Vaccine for Senior Citizen 0 0 0

Flu Vaccine for Other ages 0 0 0

Pneumo Vaccine for Senior Citizen 0 0 0

Pneumo Vaccine for Other ages 0 0 0

101
 FHSIS Version 2018

FHSIS REPORT for the: MONTH:______________ YEAR: _________

Name of HEALTH FACILITY: ____________________________________
Name of BARANGAY: ____________________________________
Municipality/City of: DUMARAN
Name Province: PALAWAN
Projected Population of the Year: ______________________
For submission to RHU
SECTION A. Family Planning Services and Deworming for Women of Reproductive Age
Age Total for WRA
A1. Modern FP Unmet Need 10-14 y/o 15-19 y/o 20-49 y/o 15-49 y/o
Remarks

1. No. of WRA with unmet need

for modern FP
ACCEPTORS
Current User Dropout Current User New Acceptors
A2. USE OF FP METHOD (Beginning Month) New Acceptors Other Acceptors (Present Month) (End of Month) of the present Month
(Previous Month) (Present Month)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 TOTAL
A. Female Sterilization/BTL 0 0 19 19 0 0 0 0 0 0 0 0 0 0 0 0 0 0 19 19 0 0 0 0
B. NSV/Vasectomy 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
C. Condom 0 0 5 5 0 0 0 0 0 0 0 0 0 0 0 0 0 0 5 5 0 0 0 0
D. Pills 0 0 21 21 0 0 0 0 0 0 0 ### 0 0 0 0 0 0 21 21 0 0 0 0
d1. Pills POP 0 0 0 0 0 0 0 0 0 0 0 ### 0 0 0 0 0 0 0 0 0 0 0 0
d2. Pills COC 0 0 21 21 0 0 0 0 0 0 0 ### 0 0 0 0 0 0 21 21 0 0 0 0
E. Injectables (DMPA/CIC) 0 3 115 118 0 0 0 0 0 0 0 ### 0 0 0 0 0 3 115 118 0 0 0 0
F. Implant 0 0 22 22 0 0 0 0 0 0 0 ### 0 0 0 0 0 0 22 22 0 0 0 0
G. IUD (IUD-I and IUD PP) 0 0 0 0 0 0 0 0 0 0 0 ### 0 0 0 0 0 0 0 0 0 0 0 0
g1. IUD- I 0 0 0 0 0 0 0 0 0 0 0 ### 0 0 0 0 0 0 0 0 0 0 0 0
g2. IUD- PP 0 0 0 0 0 0 0 0 0 0 0 ### 0 0 0 0 0 0 0 0 0 0 0 0
H. NFP-LAM 0 1 45 45 0 0 0 0 0 0 1 0 0 0 0 0 0 1 46 47 0 0 0 0
I. NFP -BBT 0 0 0 0 0 0 0 0 0 0 0 ### 0 0 0 0 0 0 0 0 0 0 0 0
J. NFP- CMM 0 0 0 0 0 0 0 0 0 0 0 ### 0 0 0 0 0 0 0 0 0 0 0 0
K. NFP- STM 0 0 0 0 0 0 0 0 0 0 0 ### 0 0 0 0 0 0 0 0 0 0 0 0
L. NFP - SDM 0 0 0 0 0 0 0 0 0 0 0 ### 0 0 0 0 0 0 0 0 0 0 0 0
TOTAL 0 4 227 230 0 0 0 0 0 0 1 ### 0 0 0 0 0 4 228 232 0 0 0 0
 FHSIS REPORT for the: MONTH:______________ YEAR: _______
Name of HEALTH FACILITY: _______________________________
Name of BARANGAY: ________________________________
Municipality/City of: DUMARAN
Name Province: PALAWAN
Projected Population of the Year: ______________________
For submission to RHU
SECTION E. Infectious Disease Prevention and Control Services
Indicators Male Female Total Remarks
E1. Filiariasis Prevention and Control (to be reported annnualy)
E2. Schistosomiasis Prevention and control
1. No. of Patients seen 0 0 0
2. No. of Suspected case seen 0 0 0
3. No. of Acute clinically diagnosed cases 0 0 0
4. No. of Confirmed acute cases 0 0 0
5. No. of Chronic clinically diagnosed cases 0 0 0
6. No. of Confirmed chronic cases 0 0 0
7. No. of Confirmed cases (Acute and Chronic) 0 0 0
8. No. of Cases treated 0 0 0
9.No. of Confirmed chronic cases referred to a hospital facility 0 0 0
E3. Soil Transmitted Helminthiasis Prevention and Control (other age groups reflected unfer Child Care and Maternal Care)
1. No. of WRA, 20-49 years old, who completed 2 doses of
deworming tablet 0 0 0
E4. HIV -AIDS/STI Prevention and control (relected under Maternal Care)
E5. Tuberculosis Prevention and Control
1. Number of Notified TB cases, All forms 0 0 0
2. No. of Registered Bacteriologically confirmed drug resistant
TB (RR/MDR-TB Cases) 0 0 0
3. Number of TB, all forms that are cured and completely treated
0 0 0
4. No. of Registered bacteriology confirmed drug resistant TB
cases (RR/MDR-TB) cured and completed treatment 0 0 0
E6. Malaria Prevention and Control
1. No. of Patients with probable/clinically diagnosed Malaria and
confirmed case 0 0 0
● < 5 y/o 0 0 0
● ≤ 5 y/o 0 0 0
2. No. of Lab-confirmed Malaria deaths 0 0 0
● < 5 y/o 0 0 0
● ≤ 5 y/o 0 0 0
E7. Leprosy Prevention and Control
1. No. of Leprosy cases on treatment during reporting period 0 0 0
2. No. of Newly detected cases during reporting period 0 0 0
E8. Rabies Prevention and Control
1. No. of Animal bites 1 1 2
2. No. of Deaths due to Rabies 0 0 0
 FHSIS REPORT for the: MONTH : ______________________ YEAR: _________
Name of Health Facility: ______________________________
Name of Barangay: ____________________________
Name of Municipality/City: DUMARAN
Name of Province: PALAWAN
Projected Population of the Year: ______________________
For submission to RHU
Section D. Oral Health Care and Services
Indicators Male Female TOTAL Remarks
1. Orally fit children 12-59 months old upon oral examination plus orally fit after rehabilation 0 0 0
2. Clients 5 years old and above with cases of DMFT 0 0 0
3. Infants 0-11months old who received BOHC 0 0 0
4. Children 1-4 years old (12-59 mos.) who received BOHC 0 0 0
5. Children 5-9 years old who received BOHC 0 0 0
6. Adolescents who received BOHC 0 0 0
a. Adolescents 10-14 years old who received BOHC 0 0 0
b. Adolescents 15-19 years old who received BOHC 0 0 0
7. Adults 20-59 years old who received BOHC 0 0 0
8. Senior citizens 60 years old and above received BOHC 0 0 0
9. Pregnant women who received BOHC 0 0 0
Section F. Non-Communicable Disease Prevention and Control Services
Indicators Male Female TOTAL Remarks
1. No. of Adults risk assessed using PhilPEN 0 0 0
2. Current smokers 0 0 0
3. Alcohol Binge drinkers 0 0 0
4. Overweight/Obese 0 0 0
5. No. of Adult Women screened for Cervical Cancer using VIA/Pap Smear 0 0 0
6. No.of Adult Women found positive/suspect for Cervival Cancer using VIA/Pap
0 0 0
Smear
7. No. of Adult Women screened for Breast Mass 0 0 0
8. No. of Adult Women with suspicious Breast Mass 0 0 0
9. No. of newly identified Hypertensive Adults 0 0 0
10. No. of newly-identified Adults with Type 2 DM 0 0 0
11. No. of Senior Citizens screened for Visual Acuity 0 0 0
12. No. of Senior Citizens diagnosed with Eye Disease/s 0 0 0
13. No. of Senior Citizens who received one dose of PPV 0 0 0
14. No. of Senior Citizens who received one dose of Influenza Vaccine 0 0 0
Section G. Environmental Health and Sanitation Services
Indicators TOTAL Remarks
1. No. of HHs with access to basic safe water supply 388

a. No. of HHs with Level I 0

b. No. of HHs with Level II 0

c. No. of HHs with Level III 388

2. No. of HHs with Basic Sanitation Facility 605

a. No of HHs with pour/flush toilet connected to septic tank 605

b. No of HHs with pour/flush connected to community 0

sewer/sewerage system ir any other approved treatment system 0
c.No. of HHs with ventilated improved pit latrine (VIP)
3. No. of Industrial Establishments issued with Sanitary Permit 0
 NATIONAL SAFE MOTHERHOOD PROGRAM
December 2020
Total deliveries by Adolescents Girls (10-19 Bacao Bohol Calasag Catep Capayas Culasian Danleg Ilian Itangil Mags
years old) 10-14 15-19 20-49TOTAL10-14 15-19 20-49TOTAL10-14 15-19 20-49TOTAL10-14 15-19 20-49TOTAL10-14 15-19 20-49TOTAL10-14 15-19 20-49TOTAL10-14 15-19 20-49TOTAL10-14 15-19 20-49TOTAL10-14 15-19 20-49TOTAL10-14

2. Women with birth plan out of total deliveries

3. Women with 4 ANC visits out of total deliveries

4. Facility Based Delivery

5. Assisted by Skilled Health Professional

6. Women with 2 PNC visits

7. Number of Pregnant Women registered for the month

8. FIC

Number of Live Births

Number of Live Births from Adolescents Mothers

9. Maternal Deaths (MMR)

10. Early Neonatal Deaths (END) (0-6 days)

11. Neonatal Deaths (0-28 days)

12. Fetal Death*

13. INFANT DEATH/S (IMR) (0-less than 1 y/o)

14. UNDER 5 MORTALITY (0-less than 5 y/o)

15. Contraceptive Prevalence Rate (CPR)

16. Teenage Pregnancy

*Fetal Death-death of the fetus prior to the complete expulsion from
the mother; the death is indicated by the fact that after separtion, the
fetus does not breath or show any evidence of life such as beating of
the
Totalheart, pulsation
deliveries of the umbilical
by adolescents cordalso
should or definite movement
be included of Deliveries
in the Total
voluntary muscles. (20 weeks and above)
# live births should also include live births from adolescent mothers.
Magsaysay Poblacion San Juan Sta. Maria Sta.Teresita Sto.Tomas Tanatanaon Over All
15-19 20-49TOTAL10-14 15-19 20-49TOTAL10-14 15-19 20-49TOTAL10-14 15-19 20-49TOTAL10-14 15-19 20-49TOTAL10-14 15-19 20-49TOTAL10-14 15-19 20-49TOTAL10-14 15-19 20-49 TOTAL
Barangay: _________________________________________Month/Year: ________________________
NATALITY Male Female TOTAL Remarks
19. Total Live Birth 1 0 1
a. Live births with weights 2,500 grams greater 1 0 1
b. Live births with less than 2,500 grams 0 0 0
c. Live births not known weight 0 0 0
20.a. Live births attended by Doctors 0 0 0
20.b. Live births attended by Nurse 0 0 0
20.c. Live births attended by Midwives 1 0 1
Live births attended by Hilot/TBA 0 0 0
Live births attended by others 0 0 0
Pregnancy 2
Normal Pregnancy 1 0 1
Risk Pregnancy 0 0 0
Unknown Pregnancy 0 0 0
Normal Deliveries 1 0 1
Normal Deliveries at Home 0 0 0
Normal Deliveries at Hospital 0 0 0
Normal Deliveries at BHS/BEMONC 1 0 1
Normal Deliveries-others (karusa, Bangka) 0 0 0
Cesarian deliveries (CS) 0 0 0
Fetal Death 0 0 0
21. No. of facility based deliveries 3
21. a. Deliveries in PUBLIC HEALTH FACILITY 3
21. b. Deliveries in PRIVATE HEALTH FACILITY 0
AGE
TOTAL Remarks
10-14 15-19 20-49
18. TOTAL DELIVERIES 0 0 1 1
23.a. No. of Vaginal deliveries 0 0 1 1
23.b. No of deliveries by Cesarian Section 0 0 0 0
24.a. No of Full term births 0 0 0 0
24. b. No. of Pre term births 0 0 0 0
24. c. No. of Fetal deaths 0 0 0 0
24. d. No. of Abortion/Miscarriage 0 0 0 0
NATIONAL SAFE MOTHERHOOD PROGRAM
10-14 15-19 20-49 TOTAL Remarks
Total deliveries by Adolescents Girls (10-19 years old) 0 0 0
1. Pregnant tracked out of total deliveries of the month 0 0 1 1
2. Women with birth plan out of total deliveries 0 0 1 1
3. Women with 4 ANC visits out of total deliveries 0 0 1 1
4. Facility Based Delivery 0 0 1 1
5. Assisted by Skilled Health Professional 0 0 1 1
6. Women with 2 PNC visits 0 0 1 1
7. Number of Pregnant Women registered for the month 0 0 5 5
8. FIC 0
Number of Live Births 0 0 1 1
Number of Live Births from Adolescents Mothers 0 0 0
9. Maternal Deaths (MMR) 0 0 0 0
10. Early Neonatal Deaths (END) (0-6 days) 0 0 0 0
11. Neonatal Deaths (0-28 days) 0 0 0 0
12. Fetal Death* 0 0 0 0
13. INFANT DEATH/S (IMR) (0-less than 0 0 0 0 0
14. UNDER 5 MORTALITY (0-less than 5 y/o) 0 0 0 0
15. Contraceptive Prevalence Rate (CPR) 0 0 0 0
16. Teenage Pregnancy 0 0 0
*Fetal Death-death of the fetus prior to the complete expulsion from the mother; the death is indicated by the fact that after
separtion, the fetus does not breath or show any evidence of life such as beating of the heart, pulsation of the umbilical cord
or definite movement of voluntary muscles. (20 weeks and above)
Total deliveries by adolescents should also be included in the Total Deliveries
# live births should also include live births from adolescent mothers.
 Month/Year: _____________________________
TEEN-AGE PREGNANCY (10-19 years old)
PRENATAL VISIT
NAME OF PREGNANT Address Age LMP EDC
(Date of Prenatal)
1st 2nd 3rd

PREGNANCY LIST (20y/o and Above)

PRENATAL VISIT
NAME OF PREGNANT Address Age LMP EDC
(Date of Prenatal)
1st 2nd 3rd
MARICEL FELIZARTE MAGSASAKA 48 8/10/2021 7/15/22 3/25/22
LINNY HERRERA MANGINGISDA 24 2-15-22 11-22-22 12/4/2022
SALVACION FUERZA MANGISNGISDA 26 5/12/2021 12/9/2022 12/4/2022
MARICEL BARING PAG-ASA 31 11/1/2022 10/18/22 4/19/22
MARIBEL BADENAS MASAGANA 33 01/17/22 10/24/22 4/19/22

See back page:HPN/DM;Mortality

Barangay: ___STA. TERESITA________ Month/Year: ___________________
HYPERTENSION AND DIABETES MELLITUS
√ If patient is HPN or DM
NAME OF PATIENT Date of Birth
Purok Age Sex Philhealth HPN DM Medicines Given
Last Name, First Name, Middle Name MM/DD/YY
MALIGAYA ARNEL M. BEBIT 37 M type 2 DM insulin

MORTALITY OF THE MONTH

NAME OF PATIENT Date of Birth Date of Place of MEDICAL (attended by Doctor/
Purok Age Sex Cause of Death
Last Name, First Name, Middle Name MMDDYY Death Death Hospital)
 FHSIS REPORT for the: MONTH : ____________ YEAR: _________
Name of Health Facility: ______________________________
Name of Barangay: ________________________
Name of Municipality/ City: DUMARAN
Name of Province: PALAWAN
Projected Population of the Year: ______________________
For submission to the next administrative level
Section A.2.a. Ten Leading Causes of Morbidity in all Age Groups
No. Name of Diseases Number of cases Rate per 100.000 population
1 ARI 2
2
3
4
5
6
7
8
9
10
Section A.2.b. Ten Leading Causes of Morbidity in Males
No. Name of Diseases Number of cases Rate per 100.000 population
1 ARI 2
2 PUNCTURED WOUND 2
3 FHMD 1
4 TONSILITIS 1
5
6
7
8
9
10
Section A.2.c. Ten Leading Causes of Morbidity in Females
No. Name of Diseases Number of cases Rate per 100.000 population
1
2
3
4
5
6
7
8
9
10
 FHSIS REPORT for the: MONTH:______________ YEAR: _________
Name of HEALTH FACILITY: ____________________________________
Name of BARANGAY: ____________________________________
Municipality/City of: DUMARAN
Name Province: PALAWAN
Projected Population of the Year: ______________________
For submission to the next administrative level
Section B. Program F1 PLUS Indicators
Indicators Male Female Total

1. No. of WRA (15-49) using modern family FP methods 232

2. No. of pregnant women w/ at least 4 prenatal check ups 1

3. No of livebirths among 15-19 y/o women 0

4. No. of livebirths with low birth weight 0

5. No. of deliveries attended by skilled health professionals 1

6. No. of postpartum women together with their newborn who

1
completed at least 2 postpartum check-ups

7. No. of health facility-based deliveries 1

8. No. of fully immunized children 0 1 9
Section C. Mortality F1 PLUS Indicators
Indicators Male Female Total
1. Maternal Deaths 0 0 0
2. Infant Deaths 0 0 0

Prepared by : ________________________________________________________ Date submitted : ____________________________

 Section A.2.d. Ten Leading Causes of Morbidity in Under-5 Children
No. Name of Diseases Number of cases Rate per 100.000 population
1
2 ARI 1
3
4
5
6
7
8
9
10
Section A.2.e. Ten Leading Causes of Morbidity in Adolescents 10-19 years old
No. Name of Diseases Number of cases Rate per 100.000 population
1 TONSILITIS 1
2
3
4
5
6
7
8
9
10
Section A.2.f. Ten Leading Causes of Morbidity in Senior Citiezens ≥60 years old
No. Name of Diseases Number of cases Rate per 100.000 population
1
2
3
4
5
6
7
8
9
10
Section A.2.f. Ten Leading Causes of Morbidity in Pregnant Women
No. Name of Diseases Number of cases Rate per 100.000 population
1
2
3
4
5
6
7
8
9
10
 FHSIS REPORT for the MONTH:MARCH YEAR:2022
. Name of Health Facility: __________________________________________

Name of Barangay:

M2
STA TERESITA

Name of Municipality: DUMARAN

Name of Province: PALAWAN

Projected Population of the Year: _____________________________________

Section A1. MORBIDITY

0-6 7-28 29 Days- 70 &

Days Days 11 Mos 1-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 ABOVE TOTAL
DISEASE
M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F TOTAL

ARI 1 1 1 1 2 2 4

TONSLITIS 1 1 0 1

PUNCTURED WOUND 1 1 2 0 2

FHMD 1 1 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
 FHSIS REPORT for the ANNUAL REPORT YEAR:____________
. Name of Health Facility: __________________________________________

Name of Barangay:

A2
_________________________________________________

Name of Municipality: ________________________________________________

Name of Province: ________________________________________________

Projected Population of the Year: _____________________________________

Section A1. MORBIDITY

0-6 7-28 29 Days- 70 &

Days Days 11 Mos 1-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 ABOVE TOTAL
DISEASE
M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F TOTAL
 FHSIS REPORT for the ANNUAL REPORT YEAR:____________
. Name of Health Facility: __________________________________________

Name of Barangay:

A3
_________________________________________________

Name of Municipality: ________________________________________________

Name of Province: ________________________________________________

Projected Population of the Year: _____________________________________

MORTALITY

0-6 7-28 29 Days- 70 &

Days Days 11 Mos 1-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 ABOVE TOTAL
CAUSE OF DEATH
M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F TOTAL