A1

FHSIS REPORT for the ANNUAL YEAR: _______

Name of Barangay: _______________________________
Name of BHS: _______________________________
Name of Municipality/City: _______________________________

RHU
Name of Province: _______________________________
Projected Population of the Year: _______________________________
For submission to RHU/MHC

Section A. Family Planning Services and Deworming for Women of Reproductive Age
Total for WRA
A1. Modern FP Unmet Need Age Remarks
15-49 y/o
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 y/o 15-19 y/o 20-49 y/o
1. No. of WRA with unmet need for modern FP - Total

A2. Use of FP Method Current Users Acceptors Drop-outs Current Users New Acceptors
(Beginning Month) New Acceptors Other Acceptors (Present Month) (End of Month) (Present Month)
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4) (Col. 5) (Col. 6) (Col. 7)
10-14 15-19 20-49 10-14 15-19 20-49 10-14 15-19 20-49 10-14 15-19 20-49 10-14 15-19 20-49 10-14 15-19 20-49
Total Total Total Total Total Total
y/o y/o y/o y/o y/o y/o y/o y/o y/o y/o y/o y/o y/o y/o y/o y/o y/o y/o
a. BTL - Total
b. NSV - Total
c. Condom - Total
d. Pills - Total
d.1 Pills-POP - Total
d.2 Pills-COC - Total
e. Injectables (DMPA/POI)-Tot.
f. Implant - Total
g. IUD (IUD-I and IUD-PP)-Tot.
g.1 IUD-I- Total
g.2 IUD-PP - Total
h. NFP-LAM - Total
i. NFP-BBT - Total
j. NFP-CMM - Total
k. NFP-STM - Total
l. NFP-SDM - Total
m. Total Current Users
Section B. Maternal Care and Services
Indicators Age Total Remarks Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col. 3) (Col. 4) (Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 10-14 15-19 20-49

1
B1. Prenatal Care
1. No. of pregnant women who gave 6. No. of pregnant women who completed
birth with at least 4 prenatal check- doses of calcium carbonate
ups - Total supplementation - Total
2. No. of pregnant women 7. No. of pregnant women given
assessed of their nutritional iodine capsules – Total
status during the 1st tri. -Total 8. No. of pregnant women given one dose
a. Number of pregnant of deworming tablet - Total
women seen in the first 9. No. of pregnant women screened for
trimester who have normal syphilis - Total
BMI - Total 10. No. of pregnant women tested positive
b. No. of pregnant women for syphilis - Total
seen in the first trimester 11. No. of pregnant women screened for
who have low BMI - Total Hepatitis B - Total
c. No. of pregnant women 12. No. of pregnant women tested positive
seen in the first trimester for Hepatitis B - Total
who have high BMI-Total 13. No. of pregnant women screened for
3. No. of pregnant women for HIV - Total
the first time given at least 2 14. No. of pregnant women tested for
doses of Td vaccination-Total CBC or Hgb & Hct count - Total
4. No. of pregnant women for 15. No. of pregnant women tested for
the 2nd or more times given CBC or Hgb & Hct count diagnosed
at least 3 doses of Td with anemia - Total
vaccination (Td2 Plus) - Total 16. No. of pregnant women screened for
5. No. of pregnant women who gestational diabetes – Total
completed the dose of iron 17. No. of pregnant women tested positive
with folic acid for gestational diabetes – Total
supplementation - Total
B2. Intrapartum Care and Delivery Outcome
18. No. of deliveries – Total 20. No. of deliveries attended by skilled
19. No. of live births – Total health professionals - Total
a. No. of live births with a. No. of deliveries attended by a
normal birth weight - Total doctor - Total
b. No. of live births with low b. No. of deliveries attended by a
birth weight - Total nurse – Total
c. No. of live births with c. No. of deliveries attended by
unknown birth weight-Total midwives - Total
Indicators Age Total Remarks Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col. 3) (Col. 4) (Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 10-14 15-19 20-49
21. No. of health facility-based 23a. No. of vaginal deliveries – Total
deliveries - Total 23b. No. of deliveries by cesarean
a. No. of deliveries in section – Total
public health facility-Total 24a. No. of full-term births – Total

2
b. No. of deliveries in 24b. No. of pre-term births – Total
private health facility-Tot. 24c. No. of fetal deaths - Total
22. No. of non-facility-based 24d. No. of abortion/miscarriage - Total
deliveries - Total
B3. Postpartum and Newborn Care
25. No. of postpartum women 27. No. of postpartum women with
together with their newborn Vitamin A supplementation – Total
who completed at least 2
postpartum check-ups -
Total
26. No. of postpartum women
who completed iron with
folic acid supplementation -
Total
Section C. Child Care and Services
Indicators Male Female Total Remarks Indicators Male Female Total Remarks
(Col. 1) (Col. 2) (Col. 3) (Col. 4) (Col. 5) (Col. 1) (Col. 2) (Col. 3) (Col. 4) (Col. 5)
C1. Immunization Services for Newborns, Infants and School-Aged Children/Adolescents
1. CPAB - Total 13. PCV 1 - Total
2. BCG - Total 14. PCV 2 - Total
3. HepB, within 24 hours. - Total 15. PCV 3 - Total
4. DPT-HiB-HepB 1 - Total 16. MCV 1 - Total
5. DPT-HiB-HepB 2 - Total 17. MCV 2 - Total
6. DPT-HiB-HepB 3 - Total 18. FIC - Total
7. OPV 1 - Total 19. CIC - Total
8. OPV 2 - Total 20. Td, Grade 1 (November) - Total
9. OPV 3 - Total 21. MR, Grade 1 (November) - Total
10. IPV 1 - Total 22. Td, Grade 7 (November) - Total
11. IPV 2 (routine)- Total 23. MR, Grade 7 (November) - Total
12. IPV 2 (catch-up)- Total
Indicators Male Female Total Remarks Indicators Male Female Total Remarks
(Col. 1) (Col. 2) (Col. 3) (Col. 4) (Col. 5) (Col. 1) (Col. 2) (Col. 3) (Col. 4) (Col. 5)
C2. Nutrition Services for Infants and Children
24. Newborns initiated on breastfeeding imme- 33. Stunted - Total
diately after birth lasting to 90 mins - Total 34. Wasted - Total
25. Preterm/LBW infants given iron 34.a. MAM - Total
supplementation - Total 34.a.1. MAM-admitted in SFT - Total
26. Infants exclusively breastfed until 5th month and 29 34.a.2. MAM-cured in SFT - Total
days - Total
27. Infants 6 mos. old initiated to complementary feeding 34.a.3. MAM-defaulted in SFT - Total
with continued breastfeeding - Total 34.a.4. MAM-died in SFT - Total
28. Infants 6 mos. old initiated to complementary feeding 34 b. SAM - Total
but no longer or never been breastfed - Total

3
28. Infants 6 mos. old initiated to complementary feeding
but no longer or never been breastfed - Total
34.b.1. SAM-admitted in OTC - Total
29. Infants 6-11 mos. given 1 dose of Vitamin A 34.b.2. SAM-cured in OTC - Total
100,000 I.U. - Total 34.b.3. SAM-defaulted in OTC - Total
30. Children 12-59 mos. old given 2 doses of 34.b.4. SAM-died in OTC - Total
Vitamin A 200,000 I.U. - Total 35. Overweight and Obese - Total
31. Infant 6-11 months old who completed MNP 36. Normal - Total
supplementation - Total
32. Children 12-23 mos. who completed MNP
supplementation - Total
C3. Deworming Services for Infants, Children and Adolescents
37. 1-19 y/o given 2 doses of deworming drug - b. SAC, 5-9 y/o dewormed (2 doses) - Total
Total c. Adolescents, 10-19 y/o dewormed (2
a. PSAC, 1-4 y/o dewormed (2 doses) - Total doses) - Total
C4. Management of Sick Infants and Children
38. Sick Infants 6-11 mos. old seen - Total 42. Diarrhea cases 0-59 months old seen - Total
39. Sick Infants 6-11 mos. old received Vitamin 43. Diarrhea cases 0-59 months old received
A - Total ORS - Total
40. Sick Children 12-59 mos. old seen - Total 44. Diarrhea cases 0-59 mos. received ORS w/
41. Sick Children 12-59 mos. old received zinc - Total
Vitamin A - Total 45. Pneumonia cases 0-59 mos. old seen - Total
46. Pneumonia cases 0-59 mos. old completed
treatment - Total
Section D. Oral Care and Services
To be submitted Quarterly
Indicators Male Female Total Remarks Indicators Male Female Total Remarks
(Col. 1) (Col. 2) (Col. 3) (Col. 4) (Col. 5) (Col. 1) (Col. 2) (Col. 3) (Col. 4) (Col. 5)
1. Orally fit children 12-59 months old upon oral 6a. Adolescents 10-14 years old who received
exam plus orally fit after rehab - Total BOHC - Total
2. Clients 5 years old and above with cases 6b. Adolescents 15-19 years old who received
of DMFT - Total BOHC - Total
3. Infants 0-11 months old who received BOHC - 7. Adults 20-59 years old who received BOHC -
Total Total
4. Children 1-4 years old who received BOHC - 8. Senior citizens 60 years old and above who
Total received BOHC - Total
5. Children 5-9 years old who received BOHC - 10-14 15-19 20-49
Total Indicators Total Remarks
y/o y/o y/o
9. Pregnant women who received BOHC - Total
Section E. Infectious Disease Prevention and Control Services
Indicators Male Female Total Remarks Indicators Male Female Total Remarks
(Col. 1) (Col. 2) (Col. 3) (Col. 4) (Col. 5) (Col. 1) (Col. 2) (Col. 3) (Col. 4) (Col. 5)
E1. Filariasis Prevention and Control (to be reported annually)
E2. Schistosomiasis Prevention and Control
1. No. of patients seen - Total 6. No. of confirmed chronic cases - Total
2. No. of suspected cases seen - Total 7. No. of confirmed cases (acute and chronic) -
Total

4
 7. No. of confirmed cases (acute and chronic) -
3. No. of acute clinically diagnosed cases - Total Total
4. No. of confirmed acute cases - Total 8. No. of cases treated - Total
5. No. of chronic clinically diagnosed cases - 9. No. of confirmed chronic cases referred to a
Total hospital facility - Total
E3. Soil Transmitted Helminthiasis Prevention and Control (other age groups reflected under Child Care and Maternal Care)
1. No. of WRA, 20-49 years old, who completed
2 doses of deworming tablet - Total
E4. HIV-AIDS/STI Prevention and Control (reflected under Maternal Care)
E5. Leprosy Prevention and Control E8. Rabies Prevention and Control
1. No. of Leprosy cases on treatment during 1. No. of animal bites - Total
reporting period - Total
2. No. of newly detected cases during 2.. No. of deaths due to Rabies - Total
reporting period - Total
Section F. Non-Communicable Disease Prevention and Control Services
Indicators Male Female Total Remarks Indicators Male Female Total Remarks
(Col. 1) (Col. 2) (Col. 3) (Col. 4) (Col. 5) (Col. 1) (Col. 2) (Col. 3) (Col. 4) (Col. 5)
1. No. of adults risk-assessed using PhilPEN - 5. No. of adult women screened for Cervical
Total Cancer using VIA/Pap Smear - Total
2. Current smokers - Total 6. No. of adult women found positive / suspect for
3. Alcohol binge drinkers - Total Cervical Cancer using VIA or Pap Smear -
4. Overweight/Obese - Total Total
Indicators Male Female Total Remarks Indicators Male Female Total Remarks
(Col. 1) (Col. 2) (Col. 3) (Col. 4) (Col. 5) (Col. 1) (Col. 2) (Col. 3) (Col. 4) (Col. 5)
7. No. of adult women screened for breast mass 11. No. of senior citizens screened for visual
- Total acuity - Total
8. No. of adult women with suspicious breast 12. No. of senior citizens diagnosed with eye
mass - Total disease/s - Total
9. No. of newly-identified hypertensive adults - 13. No. of senior citizens who received one (1)
Total dose of PPV - Total
10. No. of newly-identified adults with Type 2 DM- 14. No. of senior citizens who received one (1)
Total dose of influenza vaccine - Total
Section G. Environmental Health and Sanitation Services
Indicators Total Remarks Indicators Total Remarks
(Col. 1) (Col. 2) (Col. 3) (Col. 1) (Col. 2) (Col. 3)
1. No. of HHs with access to basic safe water supply - Total 2. No of HHs with basic sanitation facility - Total
a. No. of HHs with Level I - Total a. No. of HH with pour/flush toilet connected to septic tank - Total
b. No. of HHs with Level II - Total b. No. of HHs with pour/flush toilet connected to community
c. No. of HHs with Level III - Total sewer/sewerage system or any other approved treatment
system - Total
c. No. of HHs with ventilated improved pit latrine (VIP) - Total
3. No. of industrial establishments issued with sanitary permit - Total
Section H. Mortality Section I. Natality
Indicators Male Female Total Remarks Indicators Male Female Total Remarks
(Col. 1) (Col. 2) (Col. 3) (Col. 4) (Col. 5) (Col. 1) (Col. 2) (Col. 3) (Col. 4) (Col. 5)

5
1. Total Deaths 1. Livebirths - Total CBR:
2. Maternal Deaths - Total a. Livebirths among 15-19 y/o women-Tot. ABR:
3. Under-five Deaths - Total
4. Infant Deaths - Total
5. Neonatal Deaths - Total
6. Fetal Deaths - Total
7. Early Neonatal Deaths - Total
8. Perinatal Deaths - Total

6
 M1
FHSIS REPORT for the MONTH: ________ YEAR: _______
Name of Barangay: _______________________________
Name of BHS: _______________________________
Name of Municipality/City: _______________________________

RHU
Name of Province: _______________________________
Projected Population of the Year: _______________________________
For submission to RHU/MHC

Section A. Family Planning Services

Total for WRA
A1. Modern FP Unmet Need Age Remarks
15-49 y/o
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 y/o 15-19 y/o 20-49 y/o
1. No. of WRA with unmet need for modern FP - Total

A2. Use of FP Method Current Users Acceptors Drop-outs Current Users New Acceptors
(Beginning Month) New Acceptors Other Acceptors (Present Month) (End of Month) (Present Month)
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4) (Col. 5) (Col. 6) (Col. 7)
10-14 15-19 20-49 10-14 15-19 20-49 10-14 15-19 20-49 10-14 15-19 20-49 10-14 15-19 20-49 10-14 15-19 20-49
Total Total Total Total Total Total
y/o y/o y/o y/o y/o y/o y/o y/o y/o y/o y/o y/o y/o y/o y/o y/o y/o y/o
a. BTL - Total
b. NSV - Total
c. Condom - Total
d. Pills - Total
d.1 Pills-POP - Total
d.2 Pills-COC - Total
e. Injectables (DMPA/POI)-Tot.
f. Implant - Total
g. IUD (IUD-I and IUD-PP)-Tot.
g.1 IUD-I- Total
g.2 IUD-PP - Total
h. NFP-LAM - Total
i. NFP-BBT - Total
j. NFP-CMM - Total
k. NFP-STM - Total
l. NFP-SDM - Total
m. Total Current Users
20-49 Section A. Deworming for Women of Reproductive Age
y/o
No. of WRA given one dose of
deworming
No. of WRAtablet
given two doses of
deworming tablet Section B. Maternal Care and Services
Indicators Age Total Remarks Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col. 3) (Col. 4) (Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 10-14 15-19 20-49
B1. Prenatal Care

7
1. No. of pregnant women who gave 6. No. of pregnant women who completed
birth with at least 4 prenatal check- doses of calcium carbonate
ups - Total supplementation - Total
2. No. of pregnant women 7. No. of pregnant women given
assessed of their nutritional iodine capsules – Total
status during the 1st tri. -Total 8. No. of pregnant women given one dose
a. Number of pregnant of deworming tablet - Total
women seen in the first 9. No. of pregnant women screened for
trimester who have normal syphilis - Total
BMI - Total 10. No. of pregnant women tested positive
b. No. of pregnant women for syphilis - Total
seen in the first trimester 11. No. of pregnant women screened for
who have low BMI - Total Hepatitis B - Total
c. No. of pregnant women 12. No. of pregnant women tested positive
seen in the first trimester for Hepatitis B - Total
who have high BMI-Total 13. No. of pregnant women screened for
3. No. of pregnant women for HIV - Total
the first time given at least 2 14. No. of pregnant women tested for
doses of Td vaccination-Total CBC or Hgb & Hct count - Total
15. No. of pregnant women tested for
4. No. of pregnant women for CBC or Hgb & Hct count diagnosed
the 2nd or more times given with anemia - Total
at least 3 doses of Td
vaccination (Td2 Plus) - Total 16. No. of pregnant women screened for
gestational diabetes – Total
5. No. of pregnant women who
completed the dose of iron 17. No. of pregnant women tested positive
with folic acid for gestational diabetes – Total
supplementation - Total
B2. Intrapartum Care and Delivery Outcome
18. No. of deliveries – Total 20. No. of deliveries attended by skilled
19. No. of live births – Total health professionals - Total
a. No. of live births with a. No. of deliveries attended by a
normal birth weight - Total doctor - Total
b. No. of live births with low b. No. of deliveries attended by a
birth weight - Total nurse – Total
c. No. of live births with c. No. of deliveries attended by
unknown birth weight-Total midwives - Total
Indicators Age Total Remarks Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col. 3) (Col. 4) (Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 10-14 15-19 20-49
21. No. of health facility-based 23a. No. of vaginal deliveries – Total
deliveries - Total 23b. No. of deliveries by cesarean
a. No. of deliveries in section – Total
public health facility-Total 24a. No. of full-term births – Total
b. No. of deliveries in 24b. No. of pre-term births – Total
private health facility-Tot. 24c. No. of fetal deaths - Total
22. No. of non-facility-based 24d. No. of abortion/miscarriage - Total
deliveries - Total

8
B3. Postpartum and Newborn Care
25. No. of postpartum women 27. No. of postpartum women with
together with their newborn Vitamin A supplementation – Total
who completed at least 2
postpartum check-ups -
Total
26. No. of postpartum women
who completed iron with
folic acid supplementation -
Total
Section C. Child Care and Services
Indicators Male Female Total Remarks Indicators Male Female Total Remarks
(Col. 1) (Col. 2) (Col. 3) (Col. 4) (Col. 5) (Col. 1) (Col. 2) (Col. 3) (Col. 4) (Col. 5)
C1. Immunization Services for Newborns, Infants and School-Aged Children/Adolescents
1. CPAB - Total 13. PCV 1 - Total
2. BCG - Total 14. PCV 2 - Total
3. HepB, within 24 hours. - Total 15. PCV 3 - Total
4. DPT-HiB-HepB 1 - Total 16. MCV 1 - Total
5. DPT-HiB-HepB 2 - Total 17. MCV 2 - Total
6. DPT-HiB-HepB 3 - Total 18. FIC - Total
7. OPV 1 - Total 19. CIC - Total
8. OPV 2 - Total 20. Td, Grade 1 (November) - Total
9. OPV 3 - Total 21. MR, Grade 1 (November) - Total
10. IPV 1 - Total 22. Td, Grade 7 (November) - Total
11. IPV 2 (routine)- Total 23. MR, Grade 7 (November) - Total
12. IPV 2 (catch-up)- Total
Indicators Male Female Total Remarks Indicators Male Female Total Remarks
(Col. 1) (Col. 2) (Col. 3) (Col. 4) (Col. 5) (Col. 1) (Col. 2) (Col. 3) (Col. 4) (Col. 5)
C2. Nutrition Services for Infants and Children
24. Newborns initiated on breastfeeding imme- 33. Stunted - Total
diately after birth lasting to 90 mins - Total 34. Wasted - Total
25. Preterm/LBW infants given iron 34.a. MAM - Total
supplementation - Total 34.a.1. MAM-admitted in SFT - Total
26. Infants exclusively breastfed until 5th month and 29 34.a.2. MAM-cured in SFT - Total
days - Total
27. Infants 6 mos. old initiated to complementary feeding 34.a.3. MAM-defaulted in SFT - Total
with continued breastfeeding - Total 34.a.4. MAM-died in SFT - Total
28. Infants 6 mos. old initiated to complementary feeding 34 b. SAM - Total
but no longer or never been breastfed - Total
34.b.1. SAM-admitted in OTC - Total
29. Infants 6-11 mos. given 1 dose of Vitamin A 34.b.2. SAM-cured in OTC - Total
100,000 I.U. - Total 34.b.3. SAM-defaulted in OTC - Total
30. Children 12-59 mos. old given 2 doses of 34.b.4. SAM-died in OTC - Total
Vitamin A 200,000 I.U. - Total 35. Overweight and Obese - Total
31. Infant 6-11 months old who completed MNP 36. Normal - Total
supplementation - Total

9
32. Children 12-23 mos. who completed MNP
supplementation - Total
C3. Deworming Services for Infants, Children and Adolescents
37. 1-19 y/o given 2 doses of deworming drug - b. SAC, 5-9 y/o dewormed (2 doses) - Total
Total c. Adolescents, 10-19 y/o dewormed (2
a. PSAC, 1-4 y/o dewormed (2 doses) - Total doses) - Total
C4. Management of Sick Infants and Children
38. Sick Infants 6-11 mos. old seen - Total 42. Diarrhea cases 0-59 months old seen - Total
39. Sick Infants 6-11 mos. old received Vitamin 43. Diarrhea cases 0-59 months old received
A - Total ORS - Total
40. Sick Children 12-59 mos. old seen - Total 44. Diarrhea cases 0-59 mos. received ORS w/
41. Sick Children 12-59 mos. old received zinc - Total
Vitamin A - Total 45. Pneumonia cases 0-59 mos. old seen - Total
46. Pneumonia cases 0-59 mos. old completed
treatment - Total
Section D. Oral Care and Services
To be submitted Quarterly
Indicators Male Female Total Remarks Indicators Male Female Total Remarks
(Col. 1) (Col. 2) (Col. 3) (Col. 4) (Col. 5) (Col. 1) (Col. 2) (Col. 3) (Col. 4) (Col. 5)
1. Orally fit children 12-59 months old upon oral 6a. Adolescents 10-14 years old who received
exam plus orally fit after rehab - Total BOHC - Total
2. Clients 5 years old and above with cases 6b. Adolescents 15-19 years old who received
of DMFT - Total BOHC - Total
3. Infants 0-11 months old who received BOHC - 7. Adults 20-59 years old who received BOHC -
Total Total
4. Children 1-4 years old who received BOHC - 8. Senior citizens 60 years old and above who
Total received BOHC - Total
5. Children 5-9 years old who received BOHC - 10-14 15-19 20-49
Total Indicators Total Remarks
y/o y/o y/o
9. Pregnant women who received BOHC - Total
Section E. Infectious Disease Prevention and Control Services
Indicators Male Female Total Remarks Indicators Male Female Total Remarks
(Col. 1) (Col. 2) (Col. 3) (Col. 4) (Col. 5) (Col. 1) (Col. 2) (Col. 3) (Col. 4) (Col. 5)
E1. Filariasis Prevention and Control (to be reported annually)
E2. Schistosomiasis Prevention and Control
1. No. of patients seen - Total 6. No. of confirmed chronic cases - Total
2. No. of suspected cases seen - Total 7. No. of confirmed cases (acute and chronic) -
3. No. of acute clinically diagnosed cases - Total Total
4. No. of confirmed acute cases - Total 8. No. of cases treated - Total
5. No. of chronic clinically diagnosed cases - 9. No. of confirmed chronic cases referred to a
Total hospital facility - Total
E3. Soil Transmitted Helminthiasis Prevention and Control (other age groups reflected under Child Care and Maternal Care)
1. No. of WRA, 20-49 years old, who completed
2 doses of deworming tablet - Total
E4. HIV-AIDS/STI Prevention and Control (reflected under Maternal Care)
E5. Leprosy Prevention and Control E8. Rabies Prevention and Control
1. No. of Leprosy cases on treatment during 1. No. of animal bites - Total
reporting period - Total

10
2. No. of newly detected cases during 2.. No. of deaths due to Rabies - Total
reporting period - Total
Section F. Non-Communicable Disease Prevention and Control Services
Indicators Male Female Total Remarks Indicators Male Female Total Remarks
(Col. 1) (Col. 2) (Col. 3) (Col. 4) (Col. 5) (Col. 1) (Col. 2) (Col. 3) (Col. 4) (Col. 5)
1. No. of adults risk-assessed using PhilPEN - 5. No. of adult women screened for Cervical
Total Cancer using VIA/Pap Smear - Total
2. Current smokers - Total 6. No. of adult women found positive / suspect for
3. Alcohol binge drinkers - Total Cervical Cancer using VIA or Pap Smear -
4. Overweight/Obese - Total Total
Indicators Male Female Total Remarks Indicators Male Female Total Remarks
(Col. 1) (Col. 2) (Col. 3) (Col. 4) (Col. 5) (Col. 1) (Col. 2) (Col. 3) (Col. 4) (Col. 5)
7. No. of adult women screened for breast mass 11. No. of senior citizens screened for visual
- Total acuity - Total
8. No. of adult women with suspicious breast 12. No. of senior citizens diagnosed with eye
mass - Total disease/s - Total
9. No. of identified hypertensive adults - 13. No. of senior citizens who received one (1)
Total dose of PPV - Total
10. No. of identified adults with Type 2 DM- 14. No. of senior citizens who received one (1)
Total dose of influenza vaccine - Total
Section G. Environmental Health and Sanitation Services
Indicators Total Remarks Indicators Total Remarks
(Col. 1) (Col. 2) (Col. 3) (Col. 1) (Col. 2) (Col. 3)
1. No. of HHs with access to basic safe water supply - Total 2. No of HHs with basic sanitation facility - Total
a. No. of HHs with Level I - Total a. No. of HH with pour/flush toilet connected to septic tank - Total
b. No. of HHs with Level II - Total b. No. of HHs with pour/flush toilet connected to community
c. No. of HHs with Level III - Total sewer/sewerage system or any other approved treatment
system - Total
c. No. of HHs with ventilated improved pit latrine (VIP) - Total
3. No. of industrial establishments issued with sanitary permit - Total
Section H. Mortality Section I. Natality
Indicators Male Female Total Remarks Indicators Male Female Total Remarks
(Col. 1) (Col. 2) (Col. 3) (Col. 4) (Col. 5) (Col. 1) (Col. 2) (Col. 3) (Col. 4) (Col. 5)
1. Total Deaths 1. Livebirths - Total CBR:
2. Maternal Deaths - Total a. Livebirths among 15-19 y/o women-Tot. ABR:
3. Under-five Deaths - Total
4. Infant Deaths - Total
5. Neonatal Deaths - Total
6. Fetal Deaths - Total
7. Early Neonatal Deaths - Total
8. Perinatal Deaths - Total

11
 FHSIS REPORT for the QUARTER ________ YEAR: _______
Name of Municipality/City: __________________________________
Name of Province: __________________________________
Projected Population of the Year: __________________________________
For submission to PHO/CHO
Section A. Family Planning Services and Deworming for Women of Repr
A1. Modern FP Unmet Need Age Total for WRA 15-49
(Col. 1) (Col. 2) (Col. 3)
10-14 y/o 15-19 y/o 20-49 y/o
1. Proportion of WRA with unmet need for modern FP
(No.1.1/No.1.2 X 100)
1.1 Number of WRA with unmet need for MFP - Total
1.2 Total No. of Estimated WRA
(Total Population X 25.854%)
A2. Use of FP Method Current Users Acceptors Drop-outs Current Users
(Beginning of Qtr) New (end of Qtr) Other (end of Qtr) (Present Quarter) (End of Quarter)
(Col. 1) (Col. 2) (Col. 3) (Col. 4) (Col. 5) (Col. 6)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49
a. BTL -Total
b. NSV - Total
c. Condom - Total
d. Pills - Total
d.1 Pills-POP - Total
d.2 Pills-COC - Total
e. Injectables (DMPA/POI) - Total
f. Implant - Total
g. IUD (IUD-I and IUD-PP) - Total
g.1 IUD-I- Total

12
g.2 IUD-PP - Total
h. NFP-LAM - Total
i. NFP-BBT - Total
j. NFP-CMM - Total
k. NFP-STM - Total
l. NFP-SDM - Total
m. Total Current Users
Section A. Deworming for Women of Reproductive Age
20-49
y/o

No. of WRA given one dose of

deworming
No. of WRAtablet
given two doses of
deworming tablet

13
 Section B. Maternal Care and Services
Indicators Eligible Population / Total Deliveries Age of Pregnant/Postpartu
(Col. 3)
10-14 15-19 20-49
(Col. 1) (Col. 2) No. % No. % No.
B1. Prenatal Care
1. No. of pregnant women who gave birth w/ at least 4 prenatal check-ups - Total Total Deliveries:

2. No. of pregnant women assessed of their nutritional status during the 1st
trimester - Total
a. Number of pregnant women seen in the first trimester who have normal
BMI - Total
b. No. of pregnant women seen in the first trimester who have low BMI-Total
c. No. of pregnant women seen in the first trimester who have high BMI- Total
3. No. of pregnant women for the first time given at least 2 doses of Td
vaccination - Total
4. No. of pregnant women for the 2nd or more times given at least 3 doses of Td
vaccination (Td2 Plus) - Total
5. No. of pregnant women who completed the dose of iron with folic acid
supplementation - Total
6. No. of pregnant women who completed doses of calcium carbonate
supplementation - Total
7. No. of pregnant women given iodine capsules – Total
8. No. of pregnant women given one dose of deworming tablet - Total
9. No. of pregnant women screened for syphilis - Total
10. No. of pregnant women tested positive for syphilis - Total
11. No. of pregnant women screened for Hepatitis B - Total
12. No. of pregnant women tested positive for Hepatitis B - Total
13. No. of pregnant women screened for HIV - Total
14. No. of pregnant women tested for CBC or Hgb&Hct count - Total
15. No. of pregnant women tested for CBC or Hgb&Hct count diagnosed with
anemia - Total

14
16. No. of pregnant women screened for gestational diabetes – Total
17. No. of pregnant women tested positive for gestational diabetes – Total
B2. Intrapartum Care and Delivery Outcome
18. No. of deliveries – Total
19. No. of live births – Total
a. No. of live births with normal birth weight - Total
b. No. of live births with low birth weight - Total
c. No. of live births with unknown birth weight - Total
20. No. of deliveries attended by skilled health professionals - Total
a. No. of deliveries attended by a doctor - Total
b. No. of deliveries attended by a nurse – Total
c. No. of deliveries attended by midwives - Total

15
 Indicators Eligible Population / Total Deliveries Age of Pregnant/Postpartu
(Col. 3)
10-14 15-19 20-49
(Col. 1) (Col. 2) No. % No. % No.
21. No. of health facility-based deliveries - Total
a. No. of deliveries in public health facility - Total
b. No. of deliveries in private health facility - Total
22. No. of non-facility-based deliveries - Total
23a. No. of vaginal deliveries – Total
23b. No. of deliveries by cesarean section – Total
24a. No. of full-term births – Total
24b. No. of pre-term births – Total
24c. No. of fetal deaths - Total
24d. No. of abortion/miscarriage - Total
B3. Postpartum and Newborn Care
25. No. of postpartum women together with their newborn who completed at
Total Deliveries:
least 2 postpartum check-ups - Total
26. No. of postpartum women who completed iron with folic acid
supplementation - Total
27. No. of postpartum women with Vitamin A supplementation – Total
Section C. Child Care and Services
Indicators Eligible Population Counts
Male Female
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
C1. Immunization Services for Newborns, Infants and School-Aged Children/Adolescents
1. CPAB - Total
2. BCG - Total
3. HepB, within 24 hours. - Total
4. DPT-HiB-HepB 1 - Total
5. DPT-HiB-HepB 2 - Total
6. DPT-HiB-HepB 3 - Total
7. OPV 1 - Total

16
8. OPV 2 - Total
9. OPV 3 - Total
10. IPV 1 - Total
11. IPV 2 (routine) - Total
12. IPV 2 (catch-up) - Total
13. PCV 1 - Total
14. PCV 2 - Total
15. PCV 3 - Total
16. MCV 1 - Total
17. MCV 2 - Total
18. FIC - Total
19. CIC - Total

17
 Indicators Eligible Population Counts
Male Female
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
20. Td, Grade 1 (November) - Total
21. MR, Grade 1 (November) - Total
22. Td, Grade 7 (November) - Total
23. MR, Grade 7 (November) - Total
C2. Nutrition Services for Infants and Children
24. Newborns initiated on breastfeeding immediately after birth lasting to 90
mins - Total
25. Preterm/LBW infants given iron supplementation - Total
26. Infants exclusively breastfed until 5th month and 29 days - Total

27. Infants 6 mos. old initiated to comp, feeding w/ continued breastfeeding - Total
28. Infants 6 mos. old initiated to complementary feeding but no longer or never
been breastfed - Total
29. Infants 6-11 mos. given 1 dose of Vit. A 100,000 I.U. - Total
30. Children 12-59 mos. old given 2 doses of Vit. A 200,000 I.U. - Total
31. Infant 6-11 months old who completed MNP supplementation - Total
32. Children 12-23 mos. who completed MNP supplementation - Total
33. Stunted - Total
34. Wasted - Total
34.a. MAM - Total
34.a.1. MAM-admitted in SFT - Total
34.a.2. MAM-cured in SFT - Total
34.a.3. MAM-defaulted in SFT - Total
34.a.4. MAM-died in SFT - Total
34.b. SAM - Total
34.b.1. SAM-admitted in OTC - Total
34.b.2. SAM-cured in OTC - Total
34.b.3. SAM-defaulted in OTC - Total

18
 34.b.4. SAM-died in OTC - Total
35. Overweight and Obese - Total
36. Normal - Total
C3. Deworming Services for Infants, Children and Adolescents
37. 1-19 y/o given 2 doses of deworming drug - Total
a. PSAC, 1-4 y.o. dewormed (2 doses) - Total
b. SAC, 5-9 y.o. dewormed (2 doses) - Total
c. Adolescents, 10-19 y.o. dewormed (2 doses) - Total
C4. Management of Sick Infants and Children
38. Sick Infants 6-11 mos. old seen - Total
39. Sick Infants 6-11 mos. old received Vitamin A - Total
40. Sick Children 12-59 mos. old seen - Total
41. Sick Children 12-59 mos. old received Vitamin A - Total
42. Diarrhea cases 0-59 months old seen - Total
43. Diarrhea cases 0-59 months old received ORS - Total
44. Diarrhea cases 0-59 mos. received ORS w/ zinc - Total
45. Pneumonia cases 0-59 mos. old seen - Total
46. Pneumonia cases 0-59 mos. old completed treatment - Total
Section D. Oral Health Care and Services
Indicators Eligible Population Counts
Male Female
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
1. Orally fit children 12-59 months old upon oral examination plus orally fit after
rehabilitation - Total
2. Clients 5 years old and above with cases of DMFT - Total
3. Infants 0-11 months old who received BOHC - Total
4. Children 1-4 years old (12-59 mos.) who received BOHC - Total
5. Children 5-9 years old who received BOHC - Total

19
 Indicators Eligible Population Counts
Male Female
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
6. Adolescents who received BOHC - Total
a. Adolescents 10-14 years old who received BOHC - Total
b. Adolescents 15-19 years old who received BOHC - Total
7. Adults 20-59 years old who received BOHC - Total
8. Senior citizens 60 years old and above who received BOHC - Total
Indicators Eligible Population Counts
10-14 y/o 15-19 y/o 20-49 y/o

(Col. 1) (Col. 2) (Col. 3) (Col. 4) (Col. 5)

9. Pregnant women who received BOHC - Total
Section E. Infectious Disease Prevention and Control Service
Indicators Denominator Counts
Male Female
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
E1. Filariasis (to be reported annually)
E2. Schistosomiasis Prevention and Control
1. No. of patients seen - Total
2. No. of suspected cases seen – Total
3. No. of acute clinically diagnosed cases - Total
4. No. of confirmed acute cases - Total
5. No. of chronic clinically diagnosed cases - Total
6. No. of confirmed chronic cases - Total
7. No. of confirmed cases (acute and chronic) - Total
8. No. of cases treated - Total
9. No. of confirmed chronic cases referred to a hospital facility - Total
E3. Soil Transmitted Helminthiasis Prevention and Control (other age groups reflected under Child Care and Maternal Care)
1. No. of WRA, 20-49 years old, who completed 2 doses of deworming tablet -
Total

20
E4. HIV-AIDS/STI Prevention and Control (reflected under Maternal Care)
E5. Leprosy Prevention and Control
1. No. of Leprosy cases on treatment during reporting period - Total
2. No. of newly detected cases during reporting period - Total
E6. Rabies Prevention and Control
1. No. of animal bites - Total
2. No. of deaths due to Rabies - Total
Section F. Non-Communicable Disease Prevention and Control Se
Indicators Eligible Population/Denominator Counts
Male Female
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
1. No. of adults risk-assessed using PhilPEN - Total
2. Current smokers - Total
3. Alcohol binge drinkers - Total
4. Overweight/Obese-Total
5. No. of adult women screened for Cervical Cancer using VIA/Pap Smear -
Total
6. No. of adult women found positive/suspect for Cervical Cancer using
VIA/Pap Smear- Total
7. No. of adult women screened for breast mass - Total
8. No. of adult women with suspicious breast mass - Total
9. No. of identified hypertensive adults - Total
10. No. of identified adults with Type 2 DM - Total
11. No. of senior citizens screened for visual acuity - Total
12. No. of senior citizens diagnosed with eye disease/s - Total
13. No. of senior citizens who received one (1) dose of PPV - Total
14. No. of senior citizens who received one (1) dose of influenza vaccine - Total
Section G. Environmental Health and Sanitation Services
Indicators Target/Denominator Total

(Col. 1) (Col. 2) (Col. 3)

21
1. No. of HHs with access to basic safe water supply - Total
a. No. of HHs with Level I - Total
b. No. of HHs with Level II - Total
c. No. of HHs with Level III - Total
2. No. of HHs using safely managed drinking-water services - Total
3. No of HHs with basic sanitation facility - Total
a. No. of HH with pour/flush toilet connected to septic tank - Total
b. No. of HHs with pour/flush toilet connected to community sewer/sewerage
system or any other approved treatment system - Total
c. No. of HHs with ventilated improved pit latrine (VIP) - Total
4. No. of HHs using safely managed sanitation services - Total
5. No. of industrial establishments issued with sanitary permit - Total
6. No. of barangays declared ZOD - Total

22
 Section H. Mortality
Indicators Denominator Counts
Male Female
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
1. Total Deaths
2. Maternal Deaths - Total
3. Under-five Deaths - Total
4. Infant Deaths - Total
5. Neonatal Deaths - Total
6. Fetal Deaths - Total
7. Early Neonatal Deaths - Total
8. Perinatal Deaths - Total
Section I. Natality
Indicators Denominator Counts
Male Female
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
1. Livebirths - Total
a. Livebirths among 15-19 y/o women - Total

23
 Q1
EAR: _______
_____________
_____________

RHU
_____________
on to PHO/CHO
and Deworming for Women of Reproductive Age
Total for WRA 15-49 y/o Interpretation Recommendation / Action Taken
(Col. 3) (Col. 4) (Col. 5)

Current Users New Acceptors Interpretation Recommenda

(End of Quarter) (Last Month of tions/Actions to be Taken
(Col. 6) Present Qtr) (Col. 7)
Total 10-14 15-19 20-49 Total (Col. 9) (Col. 10)

24
Age

25
ternal Care and Services
Age of Pregnant/Postpartum Women Interpretation Recommendations /
(Col. 3) Actions to be Taken
20-49 Total
% No. % (Col. 4) (Col. 5)

26
27
 Age of Pregnant/Postpartum Women Interpretation Recommendations /
(Col. 3) Actions to be Taken
20-49 Total
% No. % (Col. 4) (Col. 5)

hild Care and Services

Counts % Interpretation Recommendations /
(Col.5/E.Pop x Actions to be Taken
Total 100)
(Col. 5) (Col. 6) (Col. 7) (Col. 8)

28
29
Counts % Interpretation Recommendations /
(Col.5/E.Pop x Actions to be Taken
Total 100)
(Col. 5) (Col. 6) (Col. 7) (Col. 8)

30
Health Care and Services
Counts % Interpretation Recommendations /
(Col.5/E.Pop x Actions to be Taken
Total 100)
(Col. 5) (Col. 6) (Col. 7) (Col. 8)

31
 Counts % Interpretation Recommendations /
(Col.5/E.Pop x Actions to be Taken
Total 100)
(Col. 5) (Col. 6) (Col. 7) (Col. 8)

Counts Interpretation Recommendations /

Total % Actions to be Taken
(Col.6/ E.Pop x 100)
(Col. 6) (Col. 7) (Col. 8) (Col. 9)

ase Prevention and Control Services

Counts % Interpretation Recommendations /
(Col.5/E.Pop x Actions to be Taken
Total 100)
(Col. 5) (Col. 6) (Col. 7) (Col. 8)

32
Disease Prevention and Control Services
Counts % Interpretation Recommendations /
(Col.5/E.Pop x Actions to be Taken
Total 100)
(Col. 5) (Col. 6) (Col. 7) (Col. 8)

tal Health and Sanitation Services

% Interpretation Recommendations /
(Col.5/Target x 100) Actions to be Taken
(Col. 4) (Col. 5) (Col. 6)

33
34
ion H. Mortality
Counts % Interpretation Recommendations /
Total Actions to be Taken
(Col. 5) (Col. 6) (Col. 7) (Col. 8)

tion I. Natality
Counts % Interpretation Recommendations /
Total Actions to be Taken
(Col. 5) (Col. 6) (Col. 7) (Col. 8)

35
 A1
FHSIS REPORT for the ANNUAL YEAR: _______
Name of Barangay: _______________________________
Name of BHS: _______________________________
Name of Municipality/City: _______________________________

BRGY
Name of Province: _______________________________
Projected Population of the Year: _______________________________
For submission to RHU/MHC

Section A. Family Planning Services and Deworming for Women of Reproductive Age
Total for WRA
A1. Modern FP Unmet Need Age Remarks
15-49 y/o
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 y/o 15-19 y/o 20-49 y/o
1. No. of WRA with unmet need for modern FP - Total

A2. Use of FP Method Current Users Acceptors Drop-outs Current Users New Acceptors
(Beginning Month) New Acceptors Other Acceptors (Present Month) (End of Month) (Present Month)
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4) (Col. 5) (Col. 6) (Col. 7)
10-14 15-19 20-49 10-14 15-19 20-49 10-14 15-19 20-49 10-14 15-19 20-49 10-14 15-19 20-49 10-14 15-19 20-49
Total Total Total Total Total Total
y/o y/o y/o y/o y/o y/o y/o y/o y/o y/o y/o y/o y/o y/o y/o y/o y/o y/o
a. BTL - Total
b. NSV - Total
c. Condom - Total
d. Pills - Total
d.1 Pills-POP - Total
d.2 Pills-COC - Total
e. Injectables (DMPA/POI)-Tot.
f. Implant - Total
g. IUD (IUD-I and IUD-PP)-Tot.
g.1 IUD-I- Total
g.2 IUD-PP - Total
h. NFP-LAM - Total
i. NFP-BBT - Total
j. NFP-CMM - Total
k. NFP-STM - Total
l. NFP-SDM - Total
m. Total Current Users
Section B. Maternal Care and Services
Indicators Age Total Remarks Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col. 3) (Col. 4) (Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 10-14 15-19 20-49

36
B1. Prenatal Care
1. No. of pregnant women who gave 6. No. of pregnant women who completed
birth with at least 4 prenatal check- doses of calcium carbonate
ups - Total supplementation - Total
2. No. of pregnant women 7. No. of pregnant women given
assessed of their nutritional iodine capsules – Total
status during the 1st tri. -Total 8. No. of pregnant women given one dose
a. Number of pregnant of deworming tablet - Total
women seen in the first 9. No. of pregnant women screened for
trimester who have normal syphilis - Total
BMI - Total 10. No. of pregnant women tested positive
b. No. of pregnant women for syphilis - Total
seen in the first trimester 11. No. of pregnant women screened for
who have low BMI - Total Hepatitis B - Total
c. No. of pregnant women 12. No. of pregnant women tested positive
seen in the first trimester for Hepatitis B - Total
who have high BMI-Total 13. No. of pregnant women screened for
3. No. of pregnant women for HIV - Total
the first time given at least 2 14. No. of pregnant women tested for
doses of Td vaccination-Total CBC or Hgb & Hct count - Total
4. No. of pregnant women for 15. No. of pregnant women tested for
the 2nd or more times given CBC or Hgb & Hct count diagnosed
at least 3 doses of Td with anemia - Total
vaccination (Td2 Plus) - Total 16. No. of pregnant women screened for
5. No. of pregnant women who gestational diabetes – Total
completed the dose of iron 17. No. of pregnant women tested positive
with folic acid for gestational diabetes – Total
supplementation - Total
B2. Intrapartum Care and Delivery Outcome
18. No. of deliveries – Total 20. No. of deliveries attended by skilled
19. No. of live births – Total health professionals - Total
a. No. of live births with a. No. of deliveries attended by a
normal birth weight - Total doctor - Total
b. No. of live births with low b. No. of deliveries attended by a
birth weight - Total nurse – Total
c. No. of live births with c. No. of deliveries attended by
unknown birth weight-Total midwives - Total
Indicators Age Total Remarks Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col. 3) (Col. 4) (Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 10-14 15-19 20-49
21. No. of health facility-based 23a. No. of vaginal deliveries – Total
deliveries - Total 23b. No. of deliveries by cesarean
a. No. of deliveries in section – Total
public health facility-Total 24a. No. of full-term births – Total

37
b. No. of deliveries in 24b. No. of pre-term births – Total
private health facility-Tot. 24c. No. of fetal deaths - Total
22. No. of non-facility-based 24d. No. of abortion/miscarriage - Total
deliveries - Total
B3. Postpartum and Newborn Care
25. No. of postpartum women 27. No. of postpartum women with
together with their newborn Vitamin A supplementation – Total
who completed at least 2
postpartum check-ups -
Total
26. No. of postpartum women
who completed iron with
folic acid supplementation -
Total
Section C. Child Care and Services
Indicators Male Female Total Remarks Indicators Male Female Total Remarks
(Col. 1) (Col. 2) (Col. 3) (Col. 4) (Col. 5) (Col. 1) (Col. 2) (Col. 3) (Col. 4) (Col. 5)
C1. Immunization Services for Newborns, Infants and School-Aged Children/Adolescents
1. CPAB - Total 13. PCV 1 - Total
2. BCG - Total 14. PCV 2 - Total
3. HepB, within 24 hours. - Total 15. PCV 3 - Total
4. DPT-HiB-HepB 1 - Total 16. MCV 1 - Total
5. DPT-HiB-HepB 2 - Total 17. MCV 2 - Total
6. DPT-HiB-HepB 3 - Total 18. FIC - Total
7. OPV 1 - Total 19. CIC - Total
8. OPV 2 - Total 20. Td, Grade 1 (November) - Total
9. OPV 3 - Total 21. MR, Grade 1 (November) - Total
10. IPV 1 - Total 22. Td, Grade 7 (November) - Total
11. IPV 2 (routine)- Total 23. MR, Grade 7 (November) - Total
12. IPV 2 (catch-up)- Total
Indicators Male Female Total Remarks Indicators Male Female Total Remarks
(Col. 1) (Col. 2) (Col. 3) (Col. 4) (Col. 5) (Col. 1) (Col. 2) (Col. 3) (Col. 4) (Col. 5)
C2. Nutrition Services for Infants and Children
24. Newborns initiated on breastfeeding imme- 33. Stunted - Total
diately after birth lasting to 90 mins - Total 34. Wasted - Total
25. Preterm/LBW infants given iron 34.a. MAM - Total
supplementation - Total 34.a.1. MAM-admitted in SFT - Total
26. Infants exclusively breastfed until 5th month and 29 34.a.2. MAM-cured in SFT - Total
days - Total
27. Infants 6 mos. old initiated to complementary feeding 34.a.3. MAM-defaulted in SFT - Total
with continued breastfeeding - Total 34.a.4. MAM-died in SFT - Total
28. Infants 6 mos. old initiated to complementary feeding 34 b. SAM - Total
but no longer or never been breastfed - Total

38
28. Infants 6 mos. old initiated to complementary feeding
but no longer or never been breastfed - Total
34.b.1. SAM-admitted in OTC - Total
29. Infants 6-11 mos. given 1 dose of Vitamin A 34.b.2. SAM-cured in OTC - Total
100,000 I.U. - Total 34.b.3. SAM-defaulted in OTC - Total
30. Children 12-59 mos. old given 2 doses of 34.b.4. SAM-died in OTC - Total
Vitamin A 200,000 I.U. - Total 35. Overweight and Obese - Total
31. Infant 6-11 months old who completed MNP 36. Normal - Total
supplementation - Total
32. Children 12-23 mos. who completed MNP
supplementation - Total
C3. Deworming Services for Infants, Children and Adolescents
37. 1-19 y/o given 2 doses of deworming drug - b. SAC, 5-9 y/o dewormed (2 doses) - Total
Total c. Adolescents, 10-19 y/o dewormed (2
a. PSAC, 1-4 y/o dewormed (2 doses) - Total doses) - Total
C4. Management of Sick Infants and Children
38. Sick Infants 6-11 mos. old seen - Total 42. Diarrhea cases 0-59 months old seen - Total
39. Sick Infants 6-11 mos. old received Vitamin 43. Diarrhea cases 0-59 months old received
A - Total ORS - Total
40. Sick Children 12-59 mos. old seen - Total 44. Diarrhea cases 0-59 mos. received ORS w/
41. Sick Children 12-59 mos. old received zinc - Total
Vitamin A - Total 45. Pneumonia cases 0-59 mos. old seen - Total
46. Pneumonia cases 0-59 mos. old completed
treatment - Total
Section D. Oral Care and Services
To be submitted Quarterly
Indicators Male Female Total Remarks Indicators Male Female Total Remarks
(Col. 1) (Col. 2) (Col. 3) (Col. 4) (Col. 5) (Col. 1) (Col. 2) (Col. 3) (Col. 4) (Col. 5)
1. Orally fit children 12-59 months old upon oral 6a. Adolescents 10-14 years old who received
exam plus orally fit after rehab - Total BOHC - Total
2. Clients 5 years old and above with cases 6b. Adolescents 15-19 years old who received
of DMFT - Total BOHC - Total
3. Infants 0-11 months old who received BOHC - 7. Adults 20-59 years old who received BOHC -
Total Total
4. Children 1-4 years old who received BOHC - 8. Senior citizens 60 years old and above who
Total received BOHC - Total
5. Children 5-9 years old who received BOHC - 10-14 15-19 20-49
Total Indicators Total Remarks
y/o y/o y/o
9. Pregnant women who received BOHC - Total
Section E. Infectious Disease Prevention and Control Services
Indicators Male Female Total Remarks Indicators Male Female Total Remarks
(Col. 1) (Col. 2) (Col. 3) (Col. 4) (Col. 5) (Col. 1) (Col. 2) (Col. 3) (Col. 4) (Col. 5)
E1. Filariasis Prevention and Control (to be reported annually)
E2. Schistosomiasis Prevention and Control
1. No. of patients seen - Total 6. No. of confirmed chronic cases - Total
2. No. of suspected cases seen - Total 7. No. of confirmed cases (acute and chronic) -
Total

39
 7. No. of confirmed cases (acute and chronic) -
3. No. of acute clinically diagnosed cases - Total Total
4. No. of confirmed acute cases - Total 8. No. of cases treated - Total
5. No. of chronic clinically diagnosed cases - 9. No. of confirmed chronic cases referred to a
Total hospital facility - Total
E3. Soil Transmitted Helminthiasis Prevention and Control (other age groups reflected under Child Care and Maternal Care)
1. No. of WRA, 20-49 years old, who completed
2 doses of deworming tablet - Total
E4. HIV-AIDS/STI Prevention and Control (reflected under Maternal Care)
E5. Leprosy Prevention and Control E8. Rabies Prevention and Control
1. No. of Leprosy cases on treatment during 1. No. of animal bites - Total
reporting period - Total
2. No. of newly detected cases during 2.. No. of deaths due to Rabies - Total
reporting period - Total
Section F. Non-Communicable Disease Prevention and Control Services
Indicators Male Female Total Remarks Indicators Male Female Total Remarks
(Col. 1) (Col. 2) (Col. 3) (Col. 4) (Col. 5) (Col. 1) (Col. 2) (Col. 3) (Col. 4) (Col. 5)
1. No. of adults risk-assessed using PhilPEN - 5. No. of adult women screened for Cervical
Total Cancer using VIA/Pap Smear - Total
2. Current smokers - Total 6. No. of adult women found positive / suspect for
3. Alcohol binge drinkers - Total Cervical Cancer using VIA or Pap Smear -
4. Overweight/Obese - Total Total
Indicators Male Female Total Remarks Indicators Male Female Total Remarks
(Col. 1) (Col. 2) (Col. 3) (Col. 4) (Col. 5) (Col. 1) (Col. 2) (Col. 3) (Col. 4) (Col. 5)
7. No. of adult women screened for breast mass 11. No. of senior citizens screened for visual
- Total acuity - Total
8. No. of adult women with suspicious breast 12. No. of senior citizens diagnosed with eye
mass - Total disease/s - Total
9. No. of newly-identified hypertensive adults - 13. No. of senior citizens who received one (1)
Total dose of PPV - Total
10. No. of newly-identified adults with Type 2 DM- 14. No. of senior citizens who received one (1)
Total dose of influenza vaccine - Total
Section G. Environmental Health and Sanitation Services
Indicators Total Remarks Indicators Total Remarks
(Col. 1) (Col. 2) (Col. 3) (Col. 1) (Col. 2) (Col. 3)
1. No. of HHs with access to basic safe water supply - Total 2. No of HHs with basic sanitation facility - Total
a. No. of HHs with Level I - Total a. No. of HH with pour/flush toilet connected to septic tank - Total
b. No. of HHs with Level II - Total b. No. of HHs with pour/flush toilet connected to community
c. No. of HHs with Level III - Total sewer/sewerage system or any other approved treatment
system - Total
c. No. of HHs with ventilated improved pit latrine (VIP) - Total
3. No. of industrial establishments issued with sanitary permit - Total
Section H. Mortality Section I. Natality
Indicators Male Female Total Remarks Indicators Male Female Total Remarks
(Col. 1) (Col. 2) (Col. 3) (Col. 4) (Col. 5) (Col. 1) (Col. 2) (Col. 3) (Col. 4) (Col. 5)

40
1. Total Deaths 1. Livebirths - Total CBR:
2. Maternal Deaths - Total a. Livebirths among 15-19 y/o women-Tot. ABR:
3. Under-five Deaths - Total
4. Infant Deaths - Total
5. Neonatal Deaths - Total
6. Fetal Deaths - Total
7. Early Neonatal Deaths - Total
8. Perinatal Deaths - Total

41
 M1
FHSIS REPORT for the MONTH: ________ YEAR: _______
Name of Barangay: _______________________________
Name of BHS: _______________________________
Name of Municipality/City: _______________________________

BRGY
Name of Province: _______________________________
Projected Population of the Year: _______________________________
For submission to RHU/MHC

Section A. Family Planning Services

Total for WRA
A1. Modern FP Unmet Need Age Remarks
15-49 y/o
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 y/o 15-19 y/o 20-49 y/o
1. No. of WRA with unmet need for modern FP - Total

A2. Use of FP Method Current Users Acceptors Drop-outs Current Users New Acceptors
(Beginning Month) New Acceptors Other Acceptors (Present Month) (End of Month) (Present Month)
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4) (Col. 5) (Col. 6) (Col. 7)
10-14 15-19 20-49 10-14 15-19 20-49 10-14 15-19 20-49 10-14 15-19 20-49 10-14 15-19 20-49 10-14 15-19 20-49
Total Total Total Total Total Total
y/o y/o y/o y/o y/o y/o y/o y/o y/o y/o y/o y/o y/o y/o y/o y/o y/o y/o
a. BTL - Total
b. NSV - Total
c. Condom - Total
d. Pills - Total
d.1 Pills-POP - Total
d.2 Pills-COC - Total
e. Injectables (DMPA/POI)-Tot.
f. Implant - Total
g. IUD (IUD-I and IUD-PP)-Tot.
g.1 IUD-I- Total
g.2 IUD-PP - Total
h. NFP-LAM - Total
i. NFP-BBT - Total
j. NFP-CMM - Total
k. NFP-STM - Total
l. NFP-SDM - Total
m. Total Current Users
20-49 Section A. Deworming for Women of Reproductive Age
y/o
No. of WRA given one dose of
deworming
No. of WRAtablet
given two doses of
deworming tablet Section B. Maternal Care and Services
Indicators Age Total Remarks Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col. 3) (Col. 4) (Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 10-14 15-19 20-49
B1. Prenatal Care
1. No. of pregnant women who gave 6. No. of pregnant women who completed
birth with at least 4 prenatal check- doses of calcium carbonate
ups - Total supplementation - Total

42
1. No. of pregnant women who gave 6. No. of pregnant women who completed
birth with at least 4 prenatal check- doses of calcium carbonate
ups - Total supplementation - Total
2. No. of pregnant women 7. No. of pregnant women given
assessed of their nutritional iodine capsules – Total
status during the 1st tri. -Total 8. No. of pregnant women given one dose
a. Number of pregnant of deworming tablet - Total
women seen in the first 9. No. of pregnant women screened for
trimester who have normal syphilis - Total
BMI - Total 10. No. of pregnant women tested positive
b. No. of pregnant women for syphilis - Total
seen in the first trimester 11. No. of pregnant women screened for
who have low BMI - Total Hepatitis B - Total
c. No. of pregnant women 12. No. of pregnant women tested positive
seen in the first trimester for Hepatitis B - Total
who have high BMI-Total 13. No. of pregnant women screened for
3. No. of pregnant women for HIV - Total
the first time given at least 2 14. No. of pregnant women tested for
doses of Td vaccination-Total CBC or Hgb & Hct count - Total
15. No. of pregnant women tested for
4. No. of pregnant women for CBC or Hgb & Hct count diagnosed
the 2nd or more times given with anemia - Total
at least 3 doses of Td
vaccination (Td2 Plus) - Total 16. No. of pregnant women screened for
gestational diabetes – Total
5. No. of pregnant women who
completed the dose of iron 17. No. of pregnant women tested positive
with folic acid for gestational diabetes – Total
supplementation - Total
B2. Intrapartum Care and Delivery Outcome
18. No. of deliveries – Total 20. No. of deliveries attended by skilled
19. No. of live births – Total health professionals - Total
a. No. of live births with a. No. of deliveries attended by a
normal birth weight - Total doctor - Total
b. No. of live births with low b. No. of deliveries attended by a
birth weight - Total nurse – Total
c. No. of live births with c. No. of deliveries attended by
unknown birth weight-Total midwives - Total
Indicators Age Total Remarks Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col. 3) (Col. 4) (Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 10-14 15-19 20-49
21. No. of health facility-based 23a. No. of vaginal deliveries – Total
deliveries - Total 23b. No. of deliveries by cesarean
a. No. of deliveries in section – Total
public health facility-Total 24a. No. of full-term births – Total
b. No. of deliveries in 24b. No. of pre-term births – Total
private health facility-Tot. 24c. No. of fetal deaths - Total
22. No. of non-facility-based 24d. No. of abortion/miscarriage - Total
deliveries - Total
B3. Postpartum and Newborn Care

43
25. No. of postpartum women 27. No. of postpartum women with
together with their newborn Vitamin A supplementation – Total
who completed at least 2
postpartum check-ups -
Total
26. No. of postpartum women
who completed iron with
folic acid supplementation -
Total
Section C. Child Care and Services
Indicators Male Female Total Remarks Indicators Male Female Total Remarks
(Col. 1) (Col. 2) (Col. 3) (Col. 4) (Col. 5) (Col. 1) (Col. 2) (Col. 3) (Col. 4) (Col. 5)
C1. Immunization Services for Newborns, Infants and School-Aged Children/Adolescents
1. CPAB - Total 13. PCV 1 - Total
2. BCG - Total 14. PCV 2 - Total
3. HepB, within 24 hours. - Total 15. PCV 3 - Total
4. DPT-HiB-HepB 1 - Total 16. MCV 1 - Total
5. DPT-HiB-HepB 2 - Total 17. MCV 2 - Total
6. DPT-HiB-HepB 3 - Total 18. FIC - Total
7. OPV 1 - Total 19. CIC - Total
8. OPV 2 - Total 20. Td, Grade 1 (November) - Total
9. OPV 3 - Total 21. MR, Grade 1 (November) - Total
10. IPV 1 - Total 22. Td, Grade 7 (November) - Total
11. IPV 2 (routine)- Total 23. MR, Grade 7 (November) - Total
12. IPV 2 (catch-up)- Total
Indicators Male Female Total Remarks Indicators Male Female Total Remarks
(Col. 1) (Col. 2) (Col. 3) (Col. 4) (Col. 5) (Col. 1) (Col. 2) (Col. 3) (Col. 4) (Col. 5)
C2. Nutrition Services for Infants and Children
24. Newborns initiated on breastfeeding imme- 33. Stunted - Total
diately after birth lasting to 90 mins - Total 34. Wasted - Total
25. Preterm/LBW infants given iron 34.a. MAM - Total
supplementation - Total 34.a.1. MAM-admitted in SFT - Total
26. Infants exclusively breastfed until 5th month and 29 34.a.2. MAM-cured in SFT - Total
days - Total
27. Infants 6 mos. old initiated to complementary feeding 34.a.3. MAM-defaulted in SFT - Total
with continued breastfeeding - Total 34.a.4. MAM-died in SFT - Total
28. Infants 6 mos. old initiated to complementary feeding 34 b. SAM - Total
but no longer or never been breastfed - Total
34.b.1. SAM-admitted in OTC - Total
29. Infants 6-11 mos. given 1 dose of Vitamin A 34.b.2. SAM-cured in OTC - Total
100,000 I.U. - Total 34.b.3. SAM-defaulted in OTC - Total
30. Children 12-59 mos. old given 2 doses of 34.b.4. SAM-died in OTC - Total
Vitamin A 200,000 I.U. - Total 35. Overweight and Obese - Total
31. Infant 6-11 months old who completed MNP 36. Normal - Total
supplementation - Total
32. Children 12-23 mos. who completed MNP
supplementation - Total
C3. Deworming Services for Infants, Children and Adolescents
37. 1-19 y/o given 2 doses of deworming drug - b. SAC, 5-9 y/o dewormed (2 doses) - Total
Total c. Adolescents, 10-19 y/o dewormed (2
doses) - Total

44
 c. Adolescents, 10-19 y/o dewormed (2
a. PSAC, 1-4 y/o dewormed (2 doses) - Total doses) - Total
C4. Management of Sick Infants and Children
38. Sick Infants 6-11 mos. old seen - Total 42. Diarrhea cases 0-59 months old seen - Total
39. Sick Infants 6-11 mos. old received Vitamin 43. Diarrhea cases 0-59 months old received
A - Total ORS - Total
40. Sick Children 12-59 mos. old seen - Total 44. Diarrhea cases 0-59 mos. received ORS w/
41. Sick Children 12-59 mos. old received zinc - Total
Vitamin A - Total 45. Pneumonia cases 0-59 mos. old seen - Total
46. Pneumonia cases 0-59 mos. old completed
treatment - Total
Section D. Oral Care and Services
To be submitted Quarterly
Indicators Male Female Total Remarks Indicators Male Female Total Remarks
(Col. 1) (Col. 2) (Col. 3) (Col. 4) (Col. 5) (Col. 1) (Col. 2) (Col. 3) (Col. 4) (Col. 5)
1. Orally fit children 12-59 months old upon oral 6a. Adolescents 10-14 years old who received
exam plus orally fit after rehab - Total BOHC - Total
2. Clients 5 years old and above with cases 6b. Adolescents 15-19 years old who received
of DMFT - Total BOHC - Total
3. Infants 0-11 months old who received BOHC - 7. Adults 20-59 years old who received BOHC -
Total Total
4. Children 1-4 years old who received BOHC - 8. Senior citizens 60 years old and above who
Total received BOHC - Total
5. Children 5-9 years old who received BOHC - 10-14 15-19 20-49
Total Indicators Total Remarks
y/o y/o y/o
9. Pregnant women who received BOHC - Total
Section E. Infectious Disease Prevention and Control Services
Indicators Male Female Total Remarks Indicators Male Female Total Remarks
(Col. 1) (Col. 2) (Col. 3) (Col. 4) (Col. 5) (Col. 1) (Col. 2) (Col. 3) (Col. 4) (Col. 5)
E1. Filariasis Prevention and Control (to be reported annually)
E2. Schistosomiasis Prevention and Control
1. No. of patients seen - Total 6. No. of confirmed chronic cases - Total
2. No. of suspected cases seen - Total 7. No. of confirmed cases (acute and chronic) -
3. No. of acute clinically diagnosed cases - Total Total
4. No. of confirmed acute cases - Total 8. No. of cases treated - Total
5. No. of chronic clinically diagnosed cases - 9. No. of confirmed chronic cases referred to a
Total hospital facility - Total
E3. Soil Transmitted Helminthiasis Prevention and Control (other age groups reflected under Child Care and Maternal Care)
1. No. of WRA, 20-49 years old, who completed
2 doses of deworming tablet - Total
E4. HIV-AIDS/STI Prevention and Control (reflected under Maternal Care)
E5. Leprosy Prevention and Control E8. Rabies Prevention and Control
1. No. of Leprosy cases on treatment during 1. No. of animal bites - Total
reporting period - Total
2. No. of newly detected cases during 2.. No. of deaths due to Rabies - Total
reporting period - Total
Section F. Non-Communicable Disease Prevention and Control Services
Indicators Male Female Total Remarks Indicators Male Female Total Remarks
(Col. 1) (Col. 2) (Col. 3) (Col. 4) (Col. 5) (Col. 1) (Col. 2) (Col. 3) (Col. 4) (Col. 5)
1. No. of adults risk-assessed using PhilPEN - 5. No. of adult women screened for Cervical
Total Cancer using VIA/Pap Smear - Total
2. Current smokers - Total 6. No. of adult women found positive / suspect for
Cervical Cancer using VIA or Pap Smear -
Total

45
 6. No. of adult women found positive / suspect for
3. Alcohol binge drinkers - Total Cervical Cancer using VIA or Pap Smear -
4. Overweight/Obese - Total Total
Indicators Male Female Total Remarks Indicators Male Female Total Remarks
(Col. 1) (Col. 2) (Col. 3) (Col. 4) (Col. 5) (Col. 1) (Col. 2) (Col. 3) (Col. 4) (Col. 5)
7. No. of adult women screened for breast mass 11. No. of senior citizens screened for visual
- Total acuity - Total
8. No. of adult women with suspicious breast 12. No. of senior citizens diagnosed with eye
mass - Total disease/s - Total
9. No. of identified hypertensive adults - 13. No. of senior citizens who received one (1)
Total dose of PPV - Total
10. No. of identified adults with Type 2 DM- 14. No. of senior citizens who received one (1)
Total dose of influenza vaccine - Total
Section G. Environmental Health and Sanitation Services
Indicators Total Remarks Indicators Total Remarks
(Col. 1) (Col. 2) (Col. 3) (Col. 1) (Col. 2) (Col. 3)
1. No. of HHs with access to basic safe water supply - Total 2. No of HHs with basic sanitation facility - Total
a. No. of HHs with Level I - Total a. No. of HH with pour/flush toilet connected to septic tank - Total
b. No. of HHs with Level II - Total b. No. of HHs with pour/flush toilet connected to community
c. No. of HHs with Level III - Total sewer/sewerage system or any other approved treatment
system - Total
c. No. of HHs with ventilated improved pit latrine (VIP) - Total
3. No. of industrial establishments issued with sanitary permit - Total
Section H. Mortality Section I. Natality
Indicators Male Female Total Remarks Indicators Male Female Total Remarks
(Col. 1) (Col. 2) (Col. 3) (Col. 4) (Col. 5) (Col. 1) (Col. 2) (Col. 3) (Col. 4) (Col. 5)
1. Total Deaths 1. Livebirths - Total CBR:
2. Maternal Deaths - Total a. Livebirths among 15-19 y/o women-Tot. ABR:
3. Under-five Deaths - Total
4. Infant Deaths - Total
5. Neonatal Deaths - Total
6. Fetal Deaths - Total
7. Early Neonatal Deaths - Total
8. Perinatal Deaths - Total

46
 FHSIS REPORT for the QUARTER: ________ YEAR: _______
Name of Municipality/City: __________________________________
Name of Province: __________________________________
Projected Population of the Year: __________________________________
For submission to PHO/CHO
Section A. Family Planning Services and Deworming for Women of Repr
A1. Modern FP Unmet Need Age Total for WRA 15-49
(Col. 1) (Col. 2) (Col. 3)
10-14 y/o 15-19 y/o 20-49 y/o
1. Proportion of WRA with unmet need for modern FP
(No.1.1/No.1.2 X 100)
1.1 Number of WRA with unmet need for MFP - Total
1.2 Total No. of Estimated WRA
(Total Population X 25.854%)
A2. Use of FP Method Current Users Acceptors Drop-outs Current Users
(Beginning of Qtr) New (end of Qtr) Other (end of Qtr) (Present Quarter) (End of Quarter)
(Col. 1) (Col. 2) (Col. 3) (Col. 4) (Col. 5) (Col. 6)
10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49 Total 10-14 15-19 20-49
a. BTL -Total
b. NSV - Total
c. Condom - Total
d. Pills - Total
d.1 Pills-POP - Total
d.2 Pills-COC - Total
e. Injectables (DMPA/POI) - Total
f. Implant - Total
g. IUD (IUD-I and IUD-PP) - Total
g.1 IUD-I- Total

47
g.2 IUD-PP - Total
h. NFP-LAM - Total
i. NFP-BBT - Total
j. NFP-CMM - Total
k. NFP-STM - Total
l. NFP-SDM - Total
m. Total Current Users
Section A. Deworming for Women of Reproductive Age
20-49
y/o

No. of WRA given one dose of

deworming
No. of WRAtablet
given two doses of
deworming tablet

48
 Section B. Maternal Care and Services
Indicators Eligible Population / Total Deliveries Age of Pregnant/Postpartu
(Col. 3)
10-14 15-19 20-49
(Col. 1) (Col. 2) No. % No. % No.
B1. Prenatal Care
1. No. of pregnant women who gave birth w/ at least 4 prenatal check-ups - Total Total Deliveries:

2. No. of pregnant women assessed of their nutritional status during the 1st
trimester - Total
a. Number of pregnant women seen in the first trimester who have normal
BMI - Total
b. No. of pregnant women seen in the first trimester who have low BMI-Total
c. No. of pregnant women seen in the first trimester who have high BMI- Total
3. No. of pregnant women for the first time given at least 2 doses of Td
vaccination - Total
4. No. of pregnant women for the 2nd or more times given at least 3 doses of Td
vaccination (Td2 Plus) - Total
5. No. of pregnant women who completed the dose of iron with folic acid
supplementation - Total
6. No. of pregnant women who completed doses of calcium carbonate
supplementation - Total
7. No. of pregnant women given iodine capsules – Total
8. No. of pregnant women given one dose of deworming tablet - Total
9. No. of pregnant women screened for syphilis - Total
10. No. of pregnant women tested positive for syphilis - Total
11. No. of pregnant women screened for Hepatitis B - Total
12. No. of pregnant women tested positive for Hepatitis B - Total
13. No. of pregnant women screened for HIV - Total
14. No. of pregnant women tested for CBC or Hgb&Hct count - Total
15. No. of pregnant women tested for CBC or Hgb&Hct count diagnosed with
anemia - Total

49
16. No. of pregnant women screened for gestational diabetes – Total
17. No. of pregnant women tested positive for gestational diabetes – Total
B2. Intrapartum Care and Delivery Outcome
18. No. of deliveries – Total
19. No. of live births – Total
a. No. of live births with normal birth weight - Total
b. No. of live births with low birth weight - Total
c. No. of live births with unknown birth weight - Total
20. No. of deliveries attended by skilled health professionals - Total
a. No. of deliveries attended by a doctor - Total
b. No. of deliveries attended by a nurse – Total
c. No. of deliveries attended by midwives - Total

50
 Indicators Eligible Population / Total Deliveries Age of Pregnant/Postpartu
(Col. 3)
10-14 15-19 20-49
(Col. 1) (Col. 2) No. % No. % No.
21. No. of health facility-based deliveries - Total
a. No. of deliveries in public health facility - Total
b. No. of deliveries in private health facility - Total
22. No. of non-facility-based deliveries - Total
23a. No. of vaginal deliveries – Total
23b. No. of deliveries by cesarean section – Total
24a. No. of full-term births – Total
24b. No. of pre-term births – Total
24c. No. of fetal deaths - Total
24d. No. of abortion/miscarriage - Total
B3. Postpartum and Newborn Care
25. No. of postpartum women together with their newborn who completed at
Total Deliveries:
least 2 postpartum check-ups - Total
26. No. of postpartum women who completed iron with folic acid
supplementation - Total
27. No. of postpartum women with Vitamin A supplementation – Total
Section C. Child Care and Services
Indicators Eligible Population Counts
Male Female
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
C1. Immunization Services for Newborns, Infants and School-Aged Children/Adolescents
1. CPAB - Total
2. BCG - Total
3. HepB, within 24 hours. - Total
4. DPT-HiB-HepB 1 - Total
5. DPT-HiB-HepB 2 - Total
6. DPT-HiB-HepB 3 - Total
7. OPV 1 - Total

51
8. OPV 2 - Total
9. OPV 3 - Total
10. IPV 1 - Total
11. IPV 2 (routine) - Total
12. IPV 2 (catch-up) - Total
13. PCV 1 - Total
14. PCV 2 - Total
15. PCV 3 - Total
16. MCV 1 - Total
17. MCV 2 - Total
18. FIC - Total
19. CIC - Total

52
 Indicators Eligible Population Counts
Male Female
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
20. Td, Grade 1 (November) - Total
21. MR, Grade 1 (November) - Total
22. Td, Grade 7 (November) - Total
23. MR, Grade 7 (November) - Total
C2. Nutrition Services for Infants and Children
24. Newborns initiated on breastfeeding immediately after birth lasting to 90
mins - Total
25. Preterm/LBW infants given iron supplementation - Total
26. Infants exclusively breastfed until 5th month and 29 days - Total

27. Infants 6 mos. old initiated to comp, feeding w/ continued breastfeeding - Total
28. Infants 6 mos. old initiated to complementary feeding but no longer or never
been breastfed - Total
29. Infants 6-11 mos. given 1 dose of Vit. A 100,000 I.U. - Total
30. Children 12-59 mos. old given 2 doses of Vit. A 200,000 I.U. - Total
31. Infant 6-11 months old who completed MNP supplementation - Total
32. Children 12-23 mos. who completed MNP supplementation - Total
33. Stunted - Total
34. Wasted - Total
34.a. MAM - Total
34.a.1. MAM-admitted in SFT - Total
34.a.2. MAM-cured in SFT - Total
34.a.3. MAM-defaulted in SFT - Total
34.a.4. MAM-died in SFT - Total
34.b. SAM - Total
34.b.1. SAM-admitted in OTC - Total
34.b.2. SAM-cured in OTC - Total
34.b.3. SAM-defaulted in OTC - Total

53
 34.b.4. SAM-died in OTC - Total
35. Overweight and Obese - Total
36. Normal - Total
C3. Deworming Services for Infants, Children and Adolescents
37. 1-19 y/o given 2 doses of deworming drug - Total
a. PSAC, 1-4 y.o. dewormed (2 doses) - Total
b. SAC, 5-9 y.o. dewormed (2 doses) - Total
c. Adolescents, 10-19 y.o. dewormed (2 doses) - Total
C4. Management of Sick Infants and Children
38. Sick Infants 6-11 mos. old seen - Total
39. Sick Infants 6-11 mos. old received Vitamin A - Total
40. Sick Children 12-59 mos. old seen - Total
41. Sick Children 12-59 mos. old received Vitamin A - Total
42. Diarrhea cases 0-59 months old seen - Total
43. Diarrhea cases 0-59 months old received ORS - Total
44. Diarrhea cases 0-59 mos. received ORS w/ zinc - Total
45. Pneumonia cases 0-59 mos. old seen - Total
46. Pneumonia cases 0-59 mos. old completed treatment - Total
Section D. Oral Health Care and Services
Indicators Eligible Population Counts
Male Female
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
1. Orally fit children 12-59 months old upon oral examination plus orally fit after
rehabilitation - Total
2. Clients 5 years old and above with cases of DMFT - Total
3. Infants 0-11 months old who received BOHC - Total
4. Children 1-4 years old (12-59 mos.) who received BOHC - Total
5. Children 5-9 years old who received BOHC - Total

54
 Indicators Eligible Population Counts
Male Female
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
6. Adolescents who received BOHC - Total
a. Adolescents 10-14 years old who received BOHC - Total
b. Adolescents 15-19 years old who received BOHC - Total
7. Adults 20-59 years old who received BOHC - Total
8. Senior citizens 60 years old and above who received BOHC - Total
Indicators Eligible Population Counts
10-14 y/o 15-19 y/o 20-49 y/o

(Col. 1) (Col. 2) (Col. 3) (Col. 4) (Col. 5)

9. Pregnant women who received BOHC - Total
Section E. Infectious Disease Prevention and Control Service
Indicators Denominator Counts
Male Female
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
E1. Filariasis (to be reported annually)
E2. Schistosomiasis Prevention and Control
1. No. of patients seen - Total
2. No. of suspected cases seen – Total
3. No. of acute clinically diagnosed cases - Total
4. No. of confirmed acute cases - Total
5. No. of chronic clinically diagnosed cases - Total
6. No. of confirmed chronic cases - Total
7. No. of confirmed cases (acute and chronic) - Total
8. No. of cases treated - Total
9. No. of confirmed chronic cases referred to a hospital facility - Total
E3. Soil Transmitted Helminthiasis Prevention and Control (other age groups reflected under Child Care and Maternal Care)
1. No. of WRA, 20-49 years old, who completed 2 doses of deworming tablet -
Total

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E4. HIV-AIDS/STI Prevention and Control (reflected under Maternal Care)
E5. Leprosy Prevention and Control
1. No. of Leprosy cases on treatment during reporting period - Total
2. No. of newly detected cases during reporting period - Total
E6. Rabies Prevention and Control
1. No. of animal bites - Total
2. No. of deaths due to Rabies - Total
Section F. Non-Communicable Disease Prevention and Control Se
Indicators Eligible Population/Denominator Counts
Male Female
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
1. No. of adults risk-assessed using PhilPEN - Total
2. Current smokers - Total
3. Alcohol binge drinkers - Total
4. Overweight/Obese-Total
5. No. of adult women screened for Cervical Cancer using VIA/Pap Smear -
Total
6. No. of adult women found positive/suspect for Cervical Cancer using
VIA/Pap Smear- Total
7. No. of adult women screened for breast mass - Total
8. No. of adult women with suspicious breast mass - Total
9. No. of identified hypertensive adults - Total
10. No. of identified adults with Type 2 DM - Total
11. No. of senior citizens screened for visual acuity - Total
12. No. of senior citizens diagnosed with eye disease/s - Total
13. No. of senior citizens who received one (1) dose of PPV - Total
14. No. of senior citizens who received one (1) dose of influenza vaccine - Total
Section G. Environmental Health and Sanitation Services
Indicators Target/Denominator Total

(Col. 1) (Col. 2) (Col. 3)

56
1. No. of HHs with access to basic safe water supply - Total
a. No. of HHs with Level I - Total
b. No. of HHs with Level II - Total
c. No. of HHs with Level III - Total
2. No. of HHs using safely managed drinking-water services - Total
3. No of HHs with basic sanitation facility - Total
a. No. of HH with pour/flush toilet connected to septic tank - Total
b. No. of HHs with pour/flush toilet connected to community sewer/sewerage
system or any other approved treatment system - Total
c. No. of HHs with ventilated improved pit latrine (VIP) - Total
4. No. of HHs using safely managed sanitation services - Total
5. No. of industrial establishments issued with sanitary permit - Total
6. No. of barangays declared ZOD - Total

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 Section H. Mortality
Indicators Denominator Counts
Male Female
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
1. Total Deaths
2. Maternal Deaths - Total
3. Under-five Deaths - Total
4. Infant Deaths - Total
5. Neonatal Deaths - Total
6. Fetal Deaths - Total
7. Early Neonatal Deaths - Total
8. Perinatal Deaths - Total
Section I. Natality
Indicators Denominator Counts
Male Female
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
1. Livebirths - Total
a. Livebirths among 15-19 y/o women - Total

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 Q1
YEAR: _______
_____________
_____________

BRGY
_____________
on to PHO/CHO
and Deworming for Women of Reproductive Age
Total for WRA 15-49 y/o Interpretation Recommendation / Action Taken
(Col. 3) (Col. 4) (Col. 5)

Current Users New Acceptors Interpretation Recommenda

(End of Quarter) (Last Month of tions/Actions to be Taken
(Col. 6) Present Qtr) (Col. 7)
Total 10-14 15-19 20-49 Total (Col. 9) (Col. 10)

59
Age

60
ternal Care and Services
Age of Pregnant/Postpartum Women Interpretation Recommendations /
(Col. 3) Actions to be Taken
20-49 Total
% No. % (Col. 4) (Col. 5)

61
62
 Age of Pregnant/Postpartum Women Interpretation Recommendations /
(Col. 3) Actions to be Taken
20-49 Total
% No. % (Col. 4) (Col. 5)

hild Care and Services

Counts % Interpretation Recommendations /
(Col.5/E.Pop x Actions to be Taken
Total 100)
(Col. 5) (Col. 6) (Col. 7) (Col. 8)

63
64
Counts % Interpretation Recommendations /
(Col.5/E.Pop x Actions to be Taken
Total 100)
(Col. 5) (Col. 6) (Col. 7) (Col. 8)

65
Health Care and Services
Counts % Interpretation Recommendations /
(Col.5/E.Pop x Actions to be Taken
Total 100)
(Col. 5) (Col. 6) (Col. 7) (Col. 8)

66
 Counts % Interpretation Recommendations /
(Col.5/E.Pop x Actions to be Taken
Total 100)
(Col. 5) (Col. 6) (Col. 7) (Col. 8)

Counts Interpretation Recommendations /

Total % Actions to be Taken
(Col.6/ E.Pop x 100)
(Col. 6) (Col. 7) (Col. 8) (Col. 9)

ase Prevention and Control Services

Counts % Interpretation Recommendations /
(Col.5/E.Pop x Actions to be Taken
Total 100)
(Col. 5) (Col. 6) (Col. 7) (Col. 8)

67
Disease Prevention and Control Services
Counts % Interpretation Recommendations /
(Col.5/E.Pop x Actions to be Taken
Total 100)
(Col. 5) (Col. 6) (Col. 7) (Col. 8)

tal Health and Sanitation Services

% Interpretation Recommendations /
(Col.5/Target x 100) Actions to be Taken
(Col. 4) (Col. 5) (Col. 6)

68
69
ion H. Mortality
Counts % Interpretation Recommendations /
Total Actions to be Taken
(Col. 5) (Col. 6) (Col. 7) (Col. 8)

tion I. Natality
Counts % Interpretation Recommendations /
Total Actions to be Taken
(Col. 5) (Col. 6) (Col. 7) (Col. 8)

70