1 ALL M1 G1 Need to encode all the data needed in the whole sheet

2 All M1 G2 highighted in YELLOW B 1, 2a-c

3 All M1 G3 highighted in YELLOW All 18-22 and 24 a-d
 FHSIS REPORT for the MONTH: __________________ YEAR: ______________

M1
Name of Barangay: _______________________________
Name of BHS: _______________________________
Name of Municipality/City: _______________________________

BRGY
Name of Province: _______________________________
Projected Population of the Year: _______________________________
For submission to RHU/MHC

Section A. Family Planning Services and Deworming for Women of Reproductive Age
Total for WRA
A1. Modern FP Unmet Need Age Remarks
Total for 15-49 y/o
(Col. 1) (Col. 2) WRA (Col. 3) (Col. 4)
Unmet
10-14 y/o 15-19 y/o 20-24y/o 25-49y/o
1. No. of WRA with unmet need for modern FP - Total

A2. Use of FP Method Current Users Acceptors Drop-outs Current Users New Acceptors
(Beginning Month) New Acceptors Other Acceptors (Present Month) (End of Month) (Present Month)
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4) (Col. 5) (Col. 6) (Col. 7)
10-14 15-19 20- 25-49 10-14 15-19 20- 25-49 10-14 15-19 20- 25-49 10-14 15-19 20- 25-49 10-14 15-19 20- 25-49 10-14 15-19 20- 25-49
Total Total Total Total Total Total
y/o y/o 24y/o y/o y/o y/o 24y/o y/o y/o y/o 24y/o y/o y/o y/o 24y/o y/o y/o y/o 24y/o y/o y/o y/o 24y/o y/o
a. BTL - Total
b. NSV - Total
c. Condom - Total
d. Pills - Total
d.1 Pills-POP - Total
d.2 Pills-COC - Total
e. Injectables (DMPA/POI)-Tot.
f. Implant - Total
g. IUD (IUD-I and IUD-PP)-Tot.
g.1 IUD-I- Total
g.2 IUD-PP - Total
h. NFP-LAM - Total
i. NFP-BBT - Total
j. NFP-CMM - Total
k. NFP-STM - Total
l. NFP-SDM - Total
m. Total Current Users

2
FHSIS REPORT for the
Name of Barangay:
Name of BHS:
Name of Municipality/City:
Name of Province:
Projected Population of the Year:
MONTH: __________________ YEAR: ______________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
For submission to RHU/MHC
3
 Section B. Maternal Care and Services
Indicators Age Total Remarks Indicators
(Col. 1) (Col. 2) (Col. 3)  (Col. 4) (Col. 1)
10-14 15-19 20- 25-49 10-14
y/o y/o 24y/o y/o y/o
B1. Prenatal Care
1. No. of pregnant women w/ 6. No. of pregnant women who completed
at least 4 prenatal check- doses of calcium carbonate
ups - Total supplementation - Total

2. No. of pregnant women 7. No. of pregnant women given

assessed of their nutritional iodine capsules – Total
status during the 1st tri. -Total
8. No. of pregnant women given one dose
of deworming tablet - Total
a. Number of pregnant
women seen in the first
trimester who have normal 9. No. of pregnant women screened for
BMI - Total syphilis - Total

10. No. of pregnant women tested positive

for syphilis - Total
b. No. of pregnant women
seen in the first trimester
who have low BMI - Total 11. No. of pregnant women screened for
Hepatitis B - Total

c. No. of pregnant women 12. No. of pregnant women tested positive

seen in the first trimester for Hepatitis B - Total
who have high BMI-Total
13. No. of pregnant women screened for
HIV - Total
3. No. of pregnant women for
the first time given at least 2
doses of Td vaccination-Total 14. No. of pregnant women tested for
CBC or Hgb & Hct count - Total

4. No. of pregnant women for 15. No. of pregnant women tested for
the 2nd or more times given CBC or Hgb & Hct count diagnosed
at least 3 doses of Td with anemia - Total
4
4. No. of pregnant women for
the 2nd or more times given
at least 3 doses of Td
vaccination (Td2 Plus) - Total
5. No. of pregnant women who
completed the dose of iron
with folic acid
supplementation - Total
5
15. No. of pregnant women tested for
CBC or Hgb & Hct count diagnosed
with anemia - Total
16. No. of pregnant women screened for
gestational diabetes – Total
17. No. of pregnant women tested positive
for gestational diabetes – Total
EAR: ______________

M1
_
_
__

BRGY
_
__
MHC

6
ernal Care and Services
Age Total Remarks
(Col. 2) (Col. 3)  (Col. 4)
15-19 20- 25-49
y/o 24y/o y/o

7
8
FHSIS REPORT for the
Name of Barangay:
Name of BHS:
Name of Municipality/City:
Name of Province:
Projected Population of the Year:
MONTH: __________________ YEAR: ______________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
For submission to RHU/MHC
9
B2. Intrapartum Care and Delivery Outcome
18. No. of deliveries – Total
19. No. of live births – Total
a. No. of live births with
normal birth weight - Total
b. No. of live births with low
birth weight - Total
c. No. of live births with
unknown birth weight-Total
Indicators Age
(Col. 1) (Col. 2)
10-14 15-19
y/o y/o
21. No. of health facility-based
deliveries - Total
a. No. of deliveries in
public health facility-Total
b. No. of deliveries in
private health facility-Tot.
22. No. of non-facility-based
deliveries - Total
B3. Postpartum and Newborn Care
25. No. of postpartum women
together with their newborn
who completed at least 2
postpartum check-ups -
Total
26. No. of postpartum women
who completed iron with
folic acid supplementation -
Total
20. No. of deliveries attended by skilled
health professionals - Total
a. No. of deliveries attended by a doctor - Total
b. No. of deliveries attended by a
nurse – Total
c. No. of deliveries attended by
midwives - Total
d. No. of deliveries attended by
hilots - Total
Total Remarks Indicators
(Col. 3)  (Col. 4)
(Col. 1)
20- 25-49 10-14
24y/o y/o y/o
23a. No. of vaginal deliveries – Total
23b. No. of deliveries by cesarean
section – Total
24a. No. of full-term births – Total
24b. No. of pre-term births – Total
24c. No. of fetal deaths - Total
24d. No. of abortion/miscarriage - Total
27. No. of postpartum women with
Vitamin A supplementation – Total

10
EAR: ______________

M1
_
_
__

BRGY
_
__
MHC

11
 Age Total Remarks
(Col. 3)  (Col. 4)
(Col. 2)
15-19 20- 25-49
y/o 24y/o y/o

12