MONITORING FORM (0-5 Months Old)

Barangay Family No.

Name of Mother Name of Father _______________________________
Occupation of the Mother: Occupation of the Father:
Name of Child Gender
Date of Birth Place of Birth
Birth Length Birth Weight
Type of Delivery ____ Single ____ Twin ____________ Others (Please specify)
Type of Birth Deliver ____ Vaginal Delivery _____ Ceasarian Section _____ VBAC (Vaginal Birth After Ceasarian)
___________________________________ Others (Please specify)
Order of Delivery ____ First ____ Second ____ Third ______________________ Others (Please specify)

IMMUNIZATION RECORD
Vaccine Date of Immunization Remarks
BCG
Hepatitis B Vaccine
Pentavalent Vaccine
Oral Polio Vaccine
Inactivated Polio Vaccine
Pneumococcal Conjugate Vaccine
Others:(Pls.Specify)______________________

INFANT AND YOUNG CHILD FEEDING

Please Check
From Birth 1 month 2 months 3 months 4 months 5 months

Introduced Breastfeeding
Immediately after delivery

Practice Exclusive
Breastfeeding
Introduced Complementary
Food

Practice Breastfeeding plus

Complementary Foods

NUTRITIONAL STATUS MONITORING

Nutritional Status
Months Length Weight Weight for Length/Height Weight for Remarks
Age for Age Length/Height

At Birth
1
2
3
4
5

OTHER SERVICES
Service Date Remarks
Vitamin A Supplementation
New Born Screening
Hearing Test
Other (Pls. Specify)______________

Still residing in barangay? ____ Yes _____ No

Submitted by: Attested by: Noted:

__________________________ ___________________________ ________________________________

F1K Coordinator Midwife Punong Barangay
 MONITORING FORM (6-23 Months Old)

Barangay Family No.

Name of Mother Name of Father
Occupation of the Mother: Occupation of the Father:
Name of Child Gender
Date of Birth Place of Birth
Birth Length Birth Weight
Type of Delivery ____ Single ____ Twin ____________ Others (Please specify)
Type of Birth Delivery ____ Vaginal Delivery _____ Ceasarian Section _____ VBAC (Vaginal Birth After Ceasarian)
___________________________________ Others (Please specify)
Order of Delivery ____ First ____ Second ____ Third ______________________ Others (Please specify)

IMMUNIZATION RECORD
Vaccine Date of Immunization Remarks
BCG
Hepatitis B Vaccine
Pentavalent Vaccine
Oral Polio Vaccine
Inactivated Polio Vaccine
Pneumococcal Conjugate Vaccine
Measles, Mumps, Rubella Vaccine
Others:(Pls.Specify)__________________________

INFANT AND YOUNG CHILD FEEDING

Please Check
From Birth 1 to 5 months 6 to 12 months 13 to 17 months 17 to 23 months Remarks

Introduced Breastfeeding
Immediately after delivery

Practice Exclusive
Breastfeeding

Introduced Complementary
Food

Practice Breastfeeding plus

Complementary Foods

NUTRITIONAL STATUS MONITORING

Nutritional Status
Months Length Weight MUAC Weight for Length/Height Weight for Remarks
Age for Age Length/Height

8
 9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

OTHER SERVICES
Service Date Remarks
Vitamin A Supplementation
Flouridization
Deworming
Other (Pls. Specify)______________

Still residing in barangay? ____ Yes _____ No

Submitted by: Attested by: Noted:

__________________________ ___________________________ ________________________________

F1K Coordinator Midwife Punong Barangay