FHSIS v.

2012

TCL-FP

TARGET CLIENT LIST FOR FAMILY PLANNING

DATE OF REGISTRATION FAMILY SERIAL NAME ADDRESS AGE Birthdate TYPE OF PRESENT/
NO. CLIENT* PREVIOUS
METHOD**
(use codes)
mm/dd/yy (use codes)
(1) (2) (3) (4) (5) (6) (7)

*Type of Client: CU = Current Users **Previous Method: CON = Condom

NA = New Acceptors INJ = DMPA or CIC NFP-BBT = Basal Body Temperature SDM = Standard Days Method
Other Acceptors: IUD = Intra-Uterine Device (PP-IUD and I-IUD) NFP-CM = Cervical Mucus Method MSTR/Vasec = Male Ster./Vasectomy
! CU-CM = Changing Method PILLS = Pills NFP-STM = Sympothermal Method FSTR/BTL = Female Ster./Bilateral Tubal Ligation
* CU-CC = Changing Clinic IMP = Single rod sub-thermal Implant NFP-LAM = Lactational Amenorrhea Method
* CU-RS = Restarter NONE or New Acceptor
FHSIS v. 2012

TCL-FP

TARGET CLIENT LIST FOR FAMILY PLANNING

FOLLOW-UP VISITS DROP-OUT REMARKS/
(Upper Space: Next Service Date / Lower Space: Date Accomplished) ACTION
TAKEN
(8) (9) (10)
1ST 2ND 3RD 4TH 5TH 6TH 7TH 8TH 9TH 10TH 11TH 12TH DATE Reason***

*** Reasons: A = Pregnant G = Menopause L = Underwent Hysterectomy For LAM:

B = Desire to become pregnant
C = Medical complications
D = Fear of side effects
E = Changed Clinic
F = Husband disapproves
H = Lost or moved out of the
area or residence
I = Failed to get supply
J = IUD expelled
K = Change method
M = Underwent Bilateral
Salpingo-oophorectomy
N = No FP commodity
O = Unknown
P = Age out for BTL
A – Mother has a menstruation or not amenorrheic within 6 mos. Or
B – No longer practicing fully/exclusively breastfeeding or
C – Baby is more than six (6) months old