BARANGAY HEALTH STATION MADUYA

Brgy. Maduya, City of Carmona, Cavite

POST – PARTUM REPORT

FAMILY DATA

Mother’s Name: ___________________________ Birthday: _______________ Age: ______

Father’s Name: ____________________________ Contact Number: ____________________
Complete Address: _____________________________________________________________

MEDICAL HISTORY

Family Planning Used before Pregnancy: ____________________

Obstetric History: G ___ P ___ / T ___ P ___ A ___ L ___
Date of First BHS Pre-Natal Check-Up: ______________________

CHILD’S INFORMATION

Child’s Name: _______________________________ Gender: ____________

Date of Birth: _____________________ Time of Birth: __________________
Birth Weight (in grams): _____________ Birth Length (in cm): ____________

Type of Birth: ______ Normal _____ CS

Name of Facility: ______________________________
Address of Facility: ____________________________
Birth AMendant: _____ MD _____ RN ______ MW ______ Others (specify): ___________

Date / Time iniOated Breast Feeding: _______________________

Tetanus Toxoid: ___ TT1 ___ TT2 ___ TT3 ___ TT4 ___ TT5
Date of New Born Screening: _______________________
Place of New Born Screening: _______________________
Result Release: ___ YES ___ NO Date Received: _____

IMMUNIZATION GIVEN TO CHILD

BCG: __________ HEPA B: __________
Started Child ImmunizaOon:

Signature of Mother: Prepared by: Noted by:

___________________ ____________________ __________________

Mothers Name BHW / FHW BHS In-Charge/Nurse

TCL Prenatal TCL NIP TCL Family Planning Recorded