54

TARGET CLIENT LIST FOR FAMILY PLANNING SERVICES

No. Date of Family Serial Complete Name Complete Address Age/ Date of SE Status Type of Client* Source** Previous Method***
Registration No. (FN, MI, LN) Birth 1 - NHTS
(mm/dd/yy) 2 - Non-NHTS

(1) (3) (4) (5) (6) (7) (8) (9)

(2)

10

* Type of Client: *** Previous Method: **** Re

NA = New Acceptors
CU = Current Users
OA = Other Acceptors
CU-CM = Changing Method
CU-CC = Changing Clinic
CU-RS = Restarter
** Source:
Public
Private
BTL = Bilateral tubal ligation NFP-LAM = Lactational Amenorrhea Method A = Pre
NSV = No-Scalpel Vasectomy NFP-BBT = Basal Body Temperature B = De
CON = Condom NFP-CMM = Cervical Mucus Method C = Me
Pills-POP = Progestin Only Pills NFP-STM = Symptothermal Method D = Fe
Pills-COC = Combined Oral Contraceptives NFP-SDM = Standard Days Method E = Ch
INJ = DMPA or CIC NONE or New Acceptor F = Hu
IMP = Single rod sub-thermal Implant G = Me
IUD-I = IUD Interval H = Lo
IUD-PP = IUD Postpartum
 55

TARGET CLIENT LIST FOR FAMILY PLANNING SERVICES

FOLLOW-UP VISITS DROP-OUT Remarks/
(Upper Space: Schedule Date of next visit / Lower Space: Actual Date of Visit) Actions Taken
(10) (11) (12)

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Date Reason****

**** Reasons:
A = Pregnant I = Failed to get supply For LAM:
B = Desire to become pregnant J = Change Method A - Mother has a menstruation or not amenorrheic within 6 months OR
C = Medical complications K = Underwent Hysterectomy B - No longer practicing fully/exclusively breastfeeding OR
D = Fear of side effects L = Underwent Bilateral Salpingo-oophorectomy C - Baby is more than six (6) months old
E = Changed Clinic M = No FP Commodity
F = Husband disapproves N = Unknown
G = Menopause O = Age out for BTL
H = Lost or moved out of the area or residence