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

LMP of Previous Pregnancy: ___________________ EDC: ____________________

Obstetric History: G _____ P _____ / T _____ P _____ A _____ L _____
Family Planning Used before Pregnancy: ____________________
Date of First BHS Pre-Natal Check-Up: ______________________
Tetanus Toxoid: ________ TT1 ________ TT2 ________ TT3 ________ TT4 ________ TT5

CHILD’S INFORMATION

Child’s Name: _______________________________ Gender: ____________

Date of Birth: _____________________ Time of Birth: __________________
Birth Weight (in grams): _____________ Birth Length (in cm): ____________
Date and Time started BreasUeeding: ________________________________
If not BreasUeeding: __________ Milk Formula __________ Mixed

Type of Birth: ______ Normal _____ CS

Name of Facility: ___________________________________ Private _______ Public ______
Address of Facility: ___________________________________________________________
Type of Facility: _____ Hospital ______ Lying-In _______ RHU ______ Home _______ Other
Birth AXendant: _____ MD _____ RN ______ MW ______ Others (specify): _____________

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 Immuniza\on: ___________________

Other Details:
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Signature of Mother: Prepared by: Noted by:

___________________ ____________________ __________________

Mothers Name BHW / FHW BHS In-Charge/Nurse