Fhsis PDF

Field Health Services
Information System

FHSIS VER. 2012
Public Health Surveillance and Informatics Division

National Epidemiology Center
Department of Health
Manila, Philippines
Message from the Director
The Field Health Services Information System (FHSIS) continues to

strengthen its goal for evidence-based decision-making at all levels of the
health management systems. FHSIS ver 2012 updates the Department of
Healths core health indicators, recording and reporting forms for better doc-
umentation. These data shall be utilized for policy directions and systems
improvement. This huge endeavour was made possible through the efforts
and collaboration with the National Epidemiology Center, National Center
for Disease Prevention and Control, Centers for Health Development and
the National Statistics Office.
Operational since 1989, FHSIS has been the official system of the DOH
and designated as national health statistics as per Executive Order 352 and
provides health services data to monitor activities in each of these programs
on routine basis (monthly, quarterly or annually) from the Barangay Health
Stations, municipality, province, cities and regions.
I am proud to present this update to enhance the data quality of the

Field Health Services Information System.
ENRIQUE A. TAYAG, MD, FPSMID, PHSAE, CESO III

Director IV
i
EDITORIAL BOARD
Enrique A. Tayag MD, PHSAE, FPSMID, CESO III

Director IV, NEC
Vito G. Roque, Jr. RMT, MD, PHSAE

Medical Specialist IV
Public Health Surveillance & Informatics Division, NEC
Vikki Carr D. de los Reyes, MD, PHSAE

Medical Specialist III
FHSIS National Coordinator, NEC
Jose M. Hernaez
Information Systems Analyst III, NEC
Joel V. Cantero
Computer Programmer III, NEC
Levi L. Lameda, RN
Nurse II, NEC
Kristine Dianne T. Toledo, RN

Nurse I, NEC
Francis Raize Nicholas Bautista, RN

Nurse I, NEC
ACKNOWLEDGEMENTS
Program Managers
Dr. Florencia Apale Mr. Edgardo Erce

Family Planning Program, NCDPC Soil Transmitted Helminthiasis Control
Program, IDO, NCDPC
Dr. Juanita Basilio
Family Health Office, NCDPC Dr. Francesca Gajete
Leprosy Program, IDO, NCDPC
Dr. Mario Baquilod
Malaria Control Program, IDO, NCDPC Dr. Leda Hernandez
Filariasis Program, IDO, NCDPC
Dr. Gerard Bellimac
National AIDS and STI Prevention and Control Ms. Liberty Importa
Program (NASPCP), IDO, NCDPC Nutrition Program, FHO, NCDPC
Dr. Anthony Calibo Ms. Ruth Martinez

Newborn Care, FHO, NCDPC Schistosomiasis Program, IDO, NCDPC
Dr. Manuel Calonge Engr. Joselito Riego de Dios

Dental Program, FHO, NCDPC Environmental Program, NCDPC
Dr. Anthony Cu Dr. Genesis Samonte

National TB Program, IDO, NCDPC HIV Surveillance, NEC
Ms. Frances Precilla Cuevas Engr. Roland Santiago

Non-Communicable Disease Program, DDO, Environmental Program, NCDPC
NCDPC
Dr. Rosalind Vianzon
Dr. Diego Danila National TB Program, IDO, NCDPC
Maternal Care Program, FHO, NCDPC
Dr. Ernesto Eusebio S. Villalon
Dr. Joyce Ducusin Leprosy Program, IDO, NCDPC
EPI Program, FHO, NCDPC

Regional FHSIS Coordinators
Ms. Myrna Gurtiza Mr. James Valencia

Statistician III Statistician II
CHD - Ilocos CHD - Zamboanga Peninsula
Dr. Marian Lynn de Laza Ms. Gloria Rodriguez

Medical Specialist III Statistician III
CHD - Cagayan Valley CHD - Northern Mindanao
Ms. Luz Campos Engr. Ma. Elizabeth Baba

Statistician III Statistician III
CHD - Central Luzon CHD - Davao
Mr. Mariano Selorio Jr. Mr. Leonardo Bautista

CHD - CALABARZON CHD - Central Mindanao
Ms. Genoveva Vias Ms. Maria Angeles de Guzman

Statistician II Statistician III
CHD - MIMAROPA CHD - CAR
Ms. Suenia Loria Mr. Paulito Ofiasa, RN

CHD - Bicol CHD - CARAGA
Ms. Alma Dumasis Ms. Maria Luz dela Cuadra

CHD - Western Visayas CHD - Metro Manila
Ms. Hermela Tan Ms. Delia Ramos

Nurse III Statistician II
CHD - Central Visayas DOH-ARMM
Ms. Lilia Mariano

Statistician III
CHD - Eastern Visayas

Acronyms
A AnnualForms
ART AltraumaticRestorativeTreatment
BBT BasalBodyTemperature
BEMONC BasicEmergencyObstetricsandNeonatalCare
BHS BarangayHealthStations
BHW BarangayHealthWorkers
BOHC BasicOralHealthCare
BTL BilateralTubalLigation
CC ChangingClinic
CMM CervicalMucusMethod
CDR CaseDetectionRate
CEMONC ComprehensiveEmergencyObstetricsandNeonatalCare
CHO CityHealthOfficer
CIC CompletelyImmunizedChild
CM ChangingMethod
CPAB ChildProtectedAtBirth
CPR ContraceptivePrevalenceRate
CU CurrentUser
CVD CardiovascularDisease
DO Dropouts
DSSM DirectSputumSmearMicroscopy
FHSIS FieldHealthServicesInformationSystem
FIC FullyImmunizedChildren
HH Household
IMR InfantMortalityRate
ITR IndividualTreatmentRecord
IUD IntrauterineDevice
LAM LactationalAmenorrheaMethod
LB Livebirth
LBW LowBirthWeight
LCR LocalCivilRegistry
LGU LocalGovernmentUnits
LHB LocalHealthBoard
LHW LocalHealthWorkers
LLIN LonglastingInsecticideNets
M MonthlyForms
MCT MonthlyConsolidationTable
MCV MeaslescontainingVaccine
MDA MassDrugAdministration
MDG MillenniumDevelopmentGoal
MFD MicrofilariaDensity
MHO MunicipalHealthOfficer
MMR MaternalMortalityRatio
MNP MicronutrientPowder
NA NewAcceptors
NBS NewbornScreening
NCDPC NationalCenterforDiseasePreventionandControl
NEC NationalEpidemiologyCenter
NHTS NationalHouseholdTargetingSystem
ORS OralRehydrationSalt
ORT OralRehydrationTherapy
OUT OralUrgentTreatment
PHN PublicHealthNurse
PN Prenatal
PP Postpartum
Q QuarterlyForms
RHM RuralHealthMidwife
RDT RapidDiagnosticTest
RHU RuralHealthUnits
RPR RapidPlasmaReagin
RS Restart/Restarter
SDM StandardDaysMethod
SSESS STISentinelEtiologicSurveillanceSystem
ST SummaryTable
STM SymptothermalMethod
SY Syphilis
TCL TargetClientList
TP TotalPopulation
TPHA TreponemaPallidumHemaglutinationAssay
TT TetanusToxoid
WHO WorldHealthOrganization
Chapter One
___________________
INTRODUCTION
FHSIS DIC 201201
1.1 Introduction
The Field Health Services Information System (FHSIS) provides the Department of Health
(DOH) with management information on the different public health programs. It is the official
system of the DOH and designated national health statistics as per Executive Order 352.
Field Health Services Information System (FHSIS) was conceptualized in 1987 as a response
to the need for streamlining an existing reporting system that, midwives complained, was
burdensome, time-consuming, and ultimately even prevented them from discharging their service
delivery functions fully. FHSIS was then implemented nationwide by 1989 in a joint effort with many
sectors within and outside the Department of Health (DOH). The FHSIS is a facility-based system,
and data generated by the system comes from the Barangay Health Stations (BHS) and Rural
Health Units (RHU). This means that, data from private or non-government units, clinics, and
institutions rendering the same services as the BHS and RHU are missed.
In 1991, barely a year after the full implementation of FHSIS, the Local Government Code
(LGC) was implemented. With this decentralization, the management and provision of health
services was transferred to the Local Government Units (LGU). In order to make the FHSIS adapt
to the changes brought about by the LGC, the FHSIS technical staff formed study teams and
undertook activities aimed at improving, simplifying, and making the system more responsive and
relevant to devolution. The team focused on simplifying and shortening Summary Tables (ST) and
reducing over-dependence on computers in the production of STs. These changes constituted the
Modified FHSIS (MFHSIS) which was implemented nationwide in 1996. However, despite the
innovations, the system continued to experience problems in its operations including poor
utilization of data for decision making by leaders in various levels of the health system, and the
sub-optimal quality of the data characterized by delayed submissions and incomplete reports.
In 2001, another revision, the Decentralized FHSIS (DFHSIS), was piloted in six areas
nationwide (three provinces and three cities) in an effort to address the shortcomings of the
MFHSIS. However, this was not implemented nationwide and was not sustained due to a very
limited information generation. An evaluation of DFHSIS was undertaken in 2004 for which findings
showed the same problems of inaccuracy, incompleteness and delay from the original FHSIS and
MFHSIS. The recommendation showed DFHSIS should not be implemented nationwide unless the
support systems are enhanced (policy and implementing rules and regulations, skilled data
managers, adequate financing and efficient computerization of the system).
In 2005, The FHSIS started its program enhancement through consultative workshops.
Program managers at the national level were met to determine indicators that would suit their
2
FHSIS DIC 201201
needs. This was followed through in recent years by series of consultations with National Center
for Disease Prevention and Control (NCDPC) Program Managers and selected Rural Health Unit
Physicians, Nurses and Midwives, Provincial Health Officers to further identify information needs
and indicators in all health management systems. FHSIS ver 2008 was developed as a result of
these meetings with Program Managers and Local Government Units (LGU). This version included
the updating of indicators needed at the national level and the FHSIS software developed by the
National Epidemiology Center (NEC).
1.2 Objectives of FHSIS ver. 2012

To update indicators based on the current needs of the health program managers and all
local government units.
1.3 Principles of FHSIS ver. 2012

Indicators needed by program managers and local government units are collected in
consultative manner. Updated FHSIS metadata are featured. FHSIS ver. 2012 shall be implemented
by 2013 with the updated indicators reports published in 2014.
1.4 Components of FHSIS ver. 2012

a. Recording Tools
Facility-based documents with more detailed data and contains day to day activities of
the health workers.
Individual Treatment Record (ITR)
Target Client List (TCL)
Summary Table (ST)
Monthly Consolidation Table (MCT)
b. Reporting Tools
These are summary data that are transmitted or submitted on a weekly, monthly,
quarterly and on annual basis to the next higher level).
Monthly Forms (M)
Quarterly Forms (Q)
Annual Forms (A-BHS, A1, A2, A3)
3
Chapter Two
___________________
COMPONENTS OF FHSIS
FHSIS DIC 201201
2.1 RECORDING TOOLS:
These are facility based documents. Data are more detailed and contains day to day
activities of the health workers. The source of data for this component is the services delivered
to patients/clients.
2.1.1 Individual Treatment Record (ITR)
The Individual Treatment Record is a document, form or piece of paper upon which is
recorded the date, name, address of patient, presenting symptoms or complaint of the
patient on consultation and the diagnosis (if available), treatment and date of treatment. This
record will be maintained as part of the system of records at each health facility on all
patients seen. This record may be as simple as the following example prepared on plain
bond paper:
Sample of ITR:
DELA CRUZ, ROSE M.
2106 Rizal Avenue, Siniloan, Laguna

Age: 32 years Birthday: February 7, 1980
Religion: Catholic Weight: 52 kg
Occupation: Housekeeper
4/15/2012
Complaint: Headache & vomiting
Vital signs: BP = 120/80 mmHG
Diagnosis:
Treatment/Recommendations:
NOTE: Do not rely on records maintained by the client/patient. In areas where the
home based maternal record is in use, there must still be a treatment record available in
the facility.
2.1.2 Target Client List (TCL)
The Target Client Lists constitute the second recording tool of the FHSIS and are
intended to serve several purposes. The tool enables the midwife or nurse to plan and
carries out patient care and service delivery. Such lists will be of considerable value to
midwives/nurses in monitoring service delivery to groups of patients identified as targets or
eligibles for a particular health program. TCL also facilitate the monitoring and supervision
of service delivery activities, report services delivered. TCL data may provide a clinic-level
data base which can be accessed for further studies.
5
FHSIS DIC 201201
The Target Client Lists to be maintained in the FHSIS version 2012 are as follows:
Target Client List for Prenatal Care
Target Client List for Post-Partum Care
Target Client List for Nutrition and Expanded Program for Immunization
Target Client List for Family Planning
Target Client List for Sick Children
Registry Forms for Filariasis, Leprosy, Malaria, Schistosomiasis and Tuberculosis shall
be the source for all Disease Control Indicators instead of a separate TCL.
2.1.3 Summary Table
The Summary Tables is a form with 12-month columns retained at the facility (BHS)
where the midwife records all monthly data. The Summary Table is composed of; a) Health
Program Accomplishment; b) Morbidity Diseases.
a. Summary Tables the midwife records a summary of all the data from TCL or
registries. This summary table is an easy source of data for reports being
prepared by the midwife. It would be wise to keep this updated as this can
serve as proof of accomplishments to show LGU officials whenever they visit
the facility. This also serves as the data source for any survey, special study,
or research that may include the facility. This can serve as a tool for the
midwife to assess her own accomplishments.
b. Morbidity Diseases the midwife accomplish this table on a monthly basis. This
summary table can also be the source of ten leading causes of morbidity and
reportable disease for the municipality/city. This summary table will help the Health
Centers staff get the monthly trend of diseases.
2.1.4 Monthly Consolidation Table (MCT)
The Monthly Consolidation Table - the Public Health Nurse (PHN) records data from all
barangays. This is the source document of the nurse for the Quarterly Form. The MCT shall
serve as the output table of the RHU as it already contains listing of indicators by barangay.
2.2 REPORTING TOOLS:
These are summary data that are transmitted or submitted on a monthly, quarterly and
on annual basis to higher level. The source of data for this component is dependent on the ST
and MCT.
6
FHSIS DIC 201201
2.2.1 The Monthly Form
2.2.1.1 Program Report (M1)
The Monthly Form contains selected indicators categorized as maternal care, child
care, family planning and disease control. The same indicators found in the TCL and
Summary Tables are found in M1. The midwife should copy the data from the Summary
Table to the Monthly Form which she regularly submits monthly to the public health nurse.
It helps the midwife capture the monthly data so that it would be easier for the nurse to
consolidate and prepare the quarterly report.
2.2.1.2 Morbidity Report (M2)
The Monthly Morbidity Disease Report contains a list of all diseases by age and
sex. The midwife uses the form for the monthly consolidation report of Morbidity Diseases
and is submitted to the PHN for quarterly consolidation.
2.2.2 The Quarterly Form
2.2.2.1 Program Report (Q1)
The Quarterly Form is the municipality/city health report and contains the three-
month total of indicators categorized as maternal care, family planning, child care, dental
health and disease control. There should only be one Quarterly Form per municipality/city.
In the event that there are two or more RHUs/MHCs in the municipality/city, the
consolidation shall be done by or under the direction of the MHO/CHO who sits as
vice chairperson of the Local Health Board (LHB). The Quarterly Form is submitted to
the Provincial Health Office (PHO) for consolidation.
2.2.2.2 Morbidity Report (Q2)
The PHN uses the form for the Quarterly Consolidation Report of Morbidity
Diseases to consolidate the Monthly Morbidity Diseases taken from the Summary Table.
The Quarterly Consolidation Report of Morbidity Diseases is submitted every third week of
the first month of the succeeding quarter.
2.2.3 The Annual Forms (A-BRGY, A1, A2 & A3)
The Annual Form 1 (A1) consists of data and indicators needed only on a yearly
basis. A-BRGY Form is the report of midwife which contains data on demographic,
environmental, natality and mortality. Annual Form 2 (A2) is the report that lists all
diseases and their occurrence in the municipality/city. The report is disaggregated by
age and sex. Annual Form 3 (A3) is the report of all deaths occurred in the
municipality/city disaggregated by age and sex.
7
FHSIS DIC 201201
2.3 RECORDING AND REPORTING TOOLS GUIDE
Locus of Recording Reporting Tools Frequency Schedule of Submission

Responsibility Tools
to higher level
Office Person
ITR Monthly Form Monthly every second week of succeeding

BHS Midwife TCL (M1 & M2) month
ST A-BRGY Form Annually every second week of January
ST Quarterly Form Quarterly every third week of the first month

MCT (Q1 & Q2) of the succeeding quarter
RHU PHN Annual Forms Annually every third week of January
> A1
> A2
> A3
Quarterly Report Quarterly every fourth week of the first
PHO/ Prov./City (Q1 & Q2) month of the succeeding quarter
CHO FHSIS Annual Report Annually every fourth week of January
Coordinator > A1
> A2
> A3
- Quarterly Report Quarterly every second week of the second
CHD Regional month of the succeeding quarter
FHSIS - Annual Report Annually every second week of March
Coordinator > A1
> A2
> A3
8
FHSIS DIC 201201
2.4 REPORTING FLOW:
9
FHSIS DIC 201201
TARGET CLIENT LIST:
2.5 Target Client List for Prenatal Care
The target client list for prenatal care will include all pregnant women eligible for pre-
natal care/service. The individual patient record or pre-natal record must still be maintained
together with this list to record information of importance to the patient which otherwise is not
included in the client list (e.g. the FHB, Wt., BP) for every pre-natal visit.
The target client list must be properly filled-up and updated as soon as possible following
a patients visit by the midwife in the BHS and the nurse/midwife in the RHU. The trained BHW
can also be given the responsibility of recording provided they are under the direct supervision of
the nurse or midwife.
Column 1 DATE OF REGISTRATION Write in this column the month, day and year a pregnant
woman was first seen at the clinic for pre-natal visit.
Column 2 FAMILY SERIAL NUMBER Enter in this column the number that corresponds to the
number of the family folder or envelope or individual treatment record. This column
will help you facilitate retrieval of clients record.
Column 3 - NAME Write the given name, middle initial and family name of the woman.
Column 4 ADDRESS Write the complete address: number of the house, name of the street,
barangay, municipality and province. This column will help you to monitor or
follow-up the client.
Column 5 AGE Write the age of the woman at her last birthday. .
Column 6 LAST NORMAL MENSTRUAL PERIOD /GRAVIDA-PARITY

LMP/GP - Write in this column 2 entries. First is the date of the last menstrual
period (month, first day of LMP and the year) followed by gravida-parity (G-P) of
the client. LMP is important because this is the basis for computing the EDC of the
mother while GP is important to know if pregnancy is of risk.
Example:
LMP/G-P
(5) (6) (7)
2-14-12/
4-3
This means that the last menstrual period of the woman was 2-14-07 and she had
4 pregnancies (gravida) including the current pregnancy and 3 deliveries (parity).
Column 7 EDC or EXPECTED DATE OF CONFINEMENT Write in this column the expected
date of delivery. This column is important for follow-up visits to prevent post maturity.
Formula for Computing EDC:

LMP: January-March = + 9 mos. +7 days + 0
April-December = - 3 mos. +7 days + 1 year
Example: LMP = 4 14 2012

Formula = - 3 + 7 + 1
EDC = 1 21 2013
10
FHSIS DIC 201201
Column 8 PRENATAL VISIT (DATES) This has 3 sub-columns representing the trimester of
pregnancy. All dates of pre-natal visits either clinic or home of a particular
pregnant woman must be entered in this column corresponding to the trimester of
pregnancy when the visit was undertaken. If a pregnant woman comes in the clinic
in the first 3 months of her pregnancy (i.e. first trimester) enter the date of that
check-up under column 8, 1st trimester. Dates of all succeeding visits should be
indicated in the appropriate trimester column. It is possible that more than one
date appears in each column. Also, visits from other DOH facilities, private
hospital/clinic should also be recorded in this column as long as there is a way to
validate that the visit is a PNV. This column is important for early detection of risk
pregnancies thus protecting both the mother and the baby.
Trimesters of Pregnancy:
The First Trimester = the first 3 months (up to 12 weeks)
The Second Trimester = the middle 3 months (13-27 weeks)
The Third Trimester = the last 3 months (28 weeks and more)
Column 9 TETANUS STATUS Write in this column the tetanus toxoid immunization already
received by the pregnant woman (either from the past pregnancy or present
pregnancy) when she made her first visit to the facility. The record of past
pregnancies can be used to obtain this information. Use the following codes:
Code
TT1 The woman has received only one dose of tetanus
toxoid during this pregnancy from other DOH facility
(e.g. transferred residence)
TT1 & TT2 The woman has received 2 doses of tetanus toxoid during
this pregnancy from other DOH facility (e.g.
transferred residence) and any woman who has
received TT1 and TT2 during the past pregnancy.
TT3 The woman has received TT1 and TT2 together with TT3
TT4 The woman has received TT1, TT2, TT3 and TT4
TT5 The woman has received TT1, TT2, TT3, TT4 and TT5
TTL Presently pregnant woman who already received
the 5 doses tetanus toxoid (Fully Immunized Mother)
NONE Women without previous history/record of
tetanus immunization or women having her pre-natal
visit for her first pregnancy
UNKNOWN If no information can be obtained from the records or
history of the woman.
Column 10 - TETANUS TOXOID VACCINATION GIVEN Write in this column

the date each tetanus toxoid is given during the course of the
present/current pregnancy.
11
FHSIS DIC 201201
Tetanus Toxoid (TT) Immunization Schedule
TT Dose Interval
As early as possible during first pregnancy or even in
TT1
a non-pregnant child bearing age woman
TT2 4 weeks after first dose within the same pregnancy
TT3 6 months after TT2

TT4 1 year after TT3
TT5 1 year after TT4
Column 11 MICRONUTRIENT SUPPLEMENTATION This has 2 sub columns, iron and

Vitamin A supplementation. For Vitamin A column, write the date and for iron
column write the date and number of iron with folic acid supplementation was
given to pregnant woman during visit.
Column 12 STI SURVEILLANCE This has 3 sub columns. For TESTED FOR SY column, put
Y for pregnant women tested for Syphilis using Rapid Plasma Reagin (RPR) or
Rapid Diagnostic Test (RDT) and put N for pregnant women not tested. For
RESULT FOR SY TESTING column, Put + if RPR or RDT result is Positive and
put - if RPR or RDT result is Negative. For GIVEN PENICILLIN column, put Y if
positive for Syphilis pregnant women was given Penicillin and put N if not.
Column 13 PREGNANCY Write the date (month, day and year) when the current pregnancy
was terminated in the sub-column DATE TERMINATED and in the OUTCOME
sub-column, write the outcome of the pregnancy whether it is a live birth, fetal
death or abortion and the sex. It is possible that two codes appear in this sub-
column. Use the following codes:
Code Definition
LB Live birth - the complete expulsion or extraction from the mothers
womb of a product of conception, irrespective after such
separation, breathes or shows any other evidence of life such
as beating of the heart, pulsation of the umbilical cord or
definite movement of muscles.
FD Fetal Death - death of the fetus prior to the complete
expulsion from the mother; the death is indicated by the
fact that after separation, the fetus does not breath or
show any evidence of life such as beating of the heart,
pulsation of the umbilical cord or definite movement of
voluntary muscles. (20 weeks and above)
AB Abortiontermination of pregnancy before the fetus becomes
viable. (before the 20th week or 5 months of pregnancy)
Code Definition
T Term newborn infants delivered more than or equal to 37 weeks completed

age of gestation (AOG) using Ballards Score Physical and Neurological
Maturity rating scale if available or through LMP or Ultrasound baby
12
FHSIS DIC 201201
PT Pre-term/Premature any newborn infants delivered less than 37 weeks

using the same definition as above.
Column 14 LIVE BIRTHS In case of Live birth, the weight of the infant in grams must appear
in the BIRTH WEIGHT sub-column. If there is more than one birth, all birth weights
in grams must appear. In the PLACE OF DELIVERY sub-column, write health
facility if delivery occurred in RHU, BeMONC, CeMONC, Hospital and lying-in
clinics; write Non-Institutional Delivery if delivery occurred otherwise (home, taxis,
etc). It is possible that two entries appear in this sub-column in case of multiple
births at different places. In the ATTENDED sub-column, write the corresponding
code of the persons designation with the highest professional rank.
Code Designation
MD Doctor
RN Nurse
RM Midwife
H Hilot/TBA
O Others
Column 15 REMARKS Make a note under this column why a pregnant woman failed to return
for the next prenatal care. Indicate dates and reasons such as transferred to
another province, presently ill, hospitalized, etc. Also include other data of
importance to the patient.
13
NAME OF BARANGAY/RHU:
MUNICIPALITY OF:
PROVINCE/CITY:
REGION:
FHSIS v. 2012
TCL-PN
TARGET CLIENT LIST FOR PRENATAL CARE
DATE OF FAMILY D A T E
REGIS- SERIAL AGE LMP/ EDC PRENATAL VISITS
NAME ADDRESS
TRATION NO. G-P (8)
mm/dd/yy FIRST SECOND THIRD
(1) (2) (3) (4) (5) (6) (7) TRIMESTER TRIMESTER TRIMESTER
NOTE: First Trimester = the first 3 months (up to 12 weeks)

Second Trimester = the middle 3 months (13-27 weeks)
Third Trimester = the last 3 months (28 weeks and more)
15
TARGET CLIENT LIST FOR PRENATAL CARE
DATE TETANUS TOXOID VACCINE STI SURVEILLANCE PREGNANCY LIVEBIRTHS
Micronutrient Supplementation
TETANUS GIVEN (12) (13) (14) REMARKS
STATUS (10) DATE & NO. TESTED RESULT FOR GIVEN DATE BIRTH PLACE OF Delivery ATTENDED
(9) IRON W/ FOLIC ACID FOR SY SY TESTING PENICILLIN TERMI- OUTCOME* WEIGHT BY ***
TT1 TT2 TT3 TT4 TT5 WAS GIVEN Y/N +/- Y/N NATED (grams) Health Facility** NID (15)
* Outcome: LB = Livebirth ** Health code: *** Attended by:

SB = Stillbirth Facility or RHU MD = Doctor
AB = Abortion Non- BeMONC RN = Nurse
Institutional CeMONC RM = Midwife
Hospital H = Hilot/TBA
lying-in clinics O = Others
16
FHSIS DIC 201201
2.6 Target Client List for Post-Partum Care
The Target Client List for Post-Partum Care will include all the women within the
catchment area who had a delivery. This list should be considered as an extension of the
TARGET CLIENT LIST FOR PRE-NATAL CARE. The names of women are entered upon
termination of pregnancy or women, whose terminations of pregnancy were not attended by the
midwife or nurse, their names are also entered in the list upon knowledge of a birth in the
catchment area, visit to facility or a home visit.
The list must be properly updated and exact dates indicated in each column by
responsible personnel i.e. the midwife in the BHS, the nurse or the midwife in the RHU or the
trained BHW under the direct supervision of the nurse or midwife.
Column 1 DATE AND TIME OF DELIVERY Write in this column the month, day, year and time
of termination of pregnancy of the mother.
Column 2 FAMILY SERIAL NUMBER Enter in this column the number that corresponds to the
number of the family folder or envelope or individual treatment record. This column will
help facilitate retrieval of clients record.
Column 3 - NAME Write the given name, middle initial and family name of the woman.
barangay, municipality and province. This column will help you to monitor or follow-up the
client.
Column 5 DATE OF POSTPARTUM VISITS This column is divided into two sub-columns.
Write the date of postpartum visits at home or at the clinic within 24 hours upon delivery
and within one week after delivery.
Column 6 DATE AND TIME INITIATED BREASTFEEDING write the date and the time post-
partum mother initiated breastfeeding.
Column 7 DATE SUPPLEMENTATION WAS GIVEN This column is divided into iron and
vitamin supplementation. For iron supplementation column, write the date/s and number of
tablet given to post-partum women. For Vitamin A, write only the date supplementation
was given.
Column 8 REMARKS Under remarks column enter information which you feel important for
post-partum care mothers.
17
MUNICIPALITY OF:
PROVINCE/CITY:
REGION:
FHSIS v. 2012
TCL-PP
CLIENT LIST FOR POSTPARTUM CARE
DATE & FAMILY DATE POST-PARTUM VISITS DATE AND MICRONUTRIENT SUPPLEMENTATION REMARKS
TIME OF SERIAL (5) TIME (7) (8)
NAME ADDRESS
DELIVERY NO. W/IN 24 HOURS WITHIN ONE INITIATED IRON VITAMIN A
AFTER WEEK AFTER BREASTFEEDING
DATE / NO. TABLETS DATE
(1) (2) (3) (4) DELIVERY DELIVERY (6)
20
FHSIS DIC 201201
2.7 Target Client List for Family Planning
The Target Client List for Family Planning will include all eligible women aged 15-49 and
men who are receiving a family planning service provided by the reporting clinic. The Family
Planning Service provided by the reporting clinic will include Condom, injectables (DMPA/CIC),
Intra-Uterine Device (IUD), NFP-Lactational Amenorrhea Method (NFP-LAM), NFP-Basal Body
Temperature (NFP-BBT), NFP-Cervical Mucus Method (NFP-CM), NFP-Sympothermal Method
(NFP-STM), NFP-Standard Days Method (NFP-SDM), Pills, Female Sterilization/Bilateral Tubal
Ligation (FSTR/BTL) and Male Sterilization/Vasectomy.
The Target Client List should be by Family Planning Method and be updated immediately
after a client visits the facility.
Column 1 DATE OF REGISTRATION Indicate in this column the date (month, day and year)
an eligible person made the first clinic visit or the date when client fail to comeback after a
year, the client has to be registered again.
Column 2 - FAMILY SERIAL NUMBER Indicate in this column the number that corresponds to
the number of the family folder or envelope or individual treatment record. This column will
help you facilitate retrieval of clients record.
Column 3 NAME Write the given name, middle initial and family name of the client.
barangay, municipality and province. This column will help you monitor or follow-up the
client.
Column 5 AGE Indicate in this column the age of the client as of last birthday.
Column 6 TYPE OF CLIENT Indicate in this column any of the applicable categories:
Code Type of Client

NA New Acceptors a client who has NEVER accepted
any FP method at any clinic before
CU Current Users current users carried over from last
month client list. Includes:
Changing Method (CM) a continuing user who is shifting

to another Method
Changing Clinic a continuing user using the same

method, however the client is new to the clinic
Restart a client who have stopped FP practice for at least

1 month and have resumed using the same method in the
same clinic.
NOTE: For clients who are changing methods/changing clinic, they should be
recorded as a DROP-OUT from their previous method and indicate the reason
as CHANGING METHOD/Changing Clinic. The client is still categorized as
current users.
20
FHSIS DIC 201201
Column 7 PREVIOUS METHOD refers to the last method used prior to accepting the new
method. Using the following codes, add code for NONE to cover New to Program.
Codes Methods
PILLS Pills
FSTR/BTL Female Sterilization/Bilateral Tubal Ligation
INJ Depo-medroxy Progestone Acetate(DMPA)/ Combined
Injectables Contraceptives(CIC)
IUD Intra-Uterine Device
NFP-BBT Natural Family Planning-Basal Body Temperature
NFP-CM Natural Family Planning-Cervical Mucus Method
NFP-STM Natural Family Planning-Symptothermal Method
SDM Natural Family Planning-Standard Days Method
LAM Lactational Amenorrhea Method
MSTR/VASECTOMY Male Sterilization/Vasectomy
CON Condom
Implants Implants
Column 8 FOLLOW-UP VISITS Write in this column 2 entries; in the upper space is the
scheduled date of visit and at the lower space is the actual date of visit. A client who is
scheduled for a particular month and failed to make the clinic visit will only have one date
entered in that particular month.
Column 9 DROP-OUT write the date client has been dropped from the TCL based on the
following method.
The following are the definitions for each method drop-out:
a. Pill - A client is considered drop-out from the method if she:
i fails to come and get her re-supply from the last 21 white
pills up to the last brown pill (if the pills have a set of brown tablets/Iron);
or within 7 days from the 21st pill / last pill (if the pills contain only a set
of white tablets)
ii gets supply or transfers to another provider or clinic: in this case, the

client is listed under the other acceptor (changed clinic) in the clinic
where she transferred and a drop out in her former clinic.
iii decided to stop the use of pills for any reason
Note: The service provider should undertake follow-up visits of the client
within this period before dropping her from the method.
b. Injectables A client is considered drop-out if she:
i fails to have a follow-up visit on the last day of 2 weeks before or after
the scheduled date of visit for DMPA; fails to have a follow-up visit on
the last day of 1 week before or after scheduled date of visit.
ii gets supply or transfers to another provider; the client is under the Other
Acceptor (Changed Clinic) in the clinic where she transferred and
considered a drop-out in her former clinic
iii stops receiving injection for any reason
21
FHSIS DIC 201201
Note: the service provider should undertake a follow-up visit during the above
period prior to dropping her out of the method.
c. IUD client is considered drop-out if:
i client decided to have it removed
ii had expelled IUD that was not re-inserted and
iii client did not return on the scheduled date of follow-up visits 3-6 weeks
after insertion from when the procedure was done. It is best medical
practice to follow-up on the client yearly, but the client is dropped out if
she does not return for two years.
d. Condom client is considered drop-out if she/he fails to return for re-supply on

scheduled visit; or decides not to use condom for any reason
e. LAM client is considered drop-out if any one of the three (3)

conditions is not met as follows:
i Mother has no menstruation or amenorrheic within six months. Spotting

or bleeding during the last fifty-six (56) days postpartum is not
considered return of menses.
ii Fully/exclusive breastfeeding means no other liquid or solid except

breastmilk be given to the infant, intervals should not exceed four hours
during the day and six hours at night.
iii Baby is less than six (6) months old
f. NFP
for Standard Days Method A client is considered a drop-out if she fails to

return on the follow-up date to identify her own fertile and infertile periods, has
no indication SDM use through beads or no knowledge of first day of
menstruation or cycle length, or decides to stop the use of the method. The
service provider should undertake a follow-up visit during the above period prior
to dropping her out.
for BBT / Billings / Symptothermal Method A client is considered a drop-out if

client fails to return on the follow-up date to check on the correct charting and/or
the proper use of the method, fails to identify her own fertile and infertile periods,
decides to stop the use of the method.
Note:
Client is given a period of time (2 months) as a learning user to practice
correct charting with assistance before recording the client as a new
acceptor. A new acceptor is considered if the client can identify and
chart her fertile and infertile period correctly.
An autonomous user can be considered a Current User as these clients

no longer need assistance in charting from the health workers.
22
FHSIS DIC 201201
The service provider should undertake a follow-up visit during the above
period prior to dropping her out.
g. Female Sterilization/ BTL - client is considered drop-out if she reaches the age beyond 49
years or experiences the following conditions: menopausal, underwent hysterectomy
or bilateral salpingo-oophorectomy.
NOTE: Follow up of clients should be undertaken prior to the dropping out of the client
from the method.
Column 10 REMARKS Indicate in this column the date and reason for every referral MADE to
other clinic and referral RECEIVED from other clinic which can be due to medical
complications or unavailable family planning services and other pertinent findings significant
to client care.
23
MUNICIPALITY OF:
PROVINCE/CITY:
REGION:
FHSIS v. 2012
TCL-FP TARGET CLIENT LIST FOR FAMILY PLANNING - ___________________

(PUT NAME OF FP METHOD
DATE OF FAMILY TYPE PREVIOUS
REGIS- SERIAL OF METHOD**
NAME ADDRESS AGE
TRATION NO. CLIENT* (use codes)
mm/dd/yy (use codes)
(1) (2) (3) (4) (5) (6) (7)
* Type of Client: CU = Current Users ** Previous Method:

NA = New Acceptors CON=Condom NFP-BBT= Basal Body Temp SDM = Standard Days Method
CU = Current Users INJ= DMPAor CIC NFP-CM= Cervical Mucus Method MSTR/Vasec = Male Ster/Vasectomy
Other Acceptors IUD = Intra-uterine Device NFP-STM= Sympothermal Method
* CU-CM = Changing Method PILLS= Pills LAM = Lactational Amenorrhea Method FSTR/BTL = Female Ster/Bilateral Tubal Ligation
*CU-CC = Changing Clinic NONE or New Acceptor
* CU-RS = Restarter
27
TARGET CLIENT LIST FOR FAMILY PLANNING
FOLLOW-UP VISITS
(Upper Space: Next Service Date / Lower Space: Date Accomplished) REMARKS/
DROP-OUT
ACTION
(8) (9) TAKEN
1ST 2ND 3RD 4TH 5TH 6TH 7TH 8TH 9TH 10TH 11TH 12TH DATE Reason (10)
***Reasons: A = Pregnant F = Husband disapproves K = Change Method For LAM:

B = Desire to become pregnant G = Menopause L = Underwent Hysterectomy A - Mother has a menstruation or not amenorrheic within 6 mos. or
C = Medical complications H = Lost or moved out of the area or residence M= Underwent Bilateral Salpingo-oophorectomy B - No longer practicing fully/exclusively breastfeeding or
D = Fear of side effects I = Failed to get supply N = No FP Commodity C - Baby is more than six (6) months old
E = Changed Clinic J = IUD expelled O = Unknown
P = Age out for BTL
27
FHSIS DIC 201201
2.8 Target Client List for Nutrition and Expanded Program for Immunization Part I
The Target Client List for Nutrition and Expanded Program for Immunization should include all children under
one year old eligible for immunization against the most common vaccine-preventable disease that results to
permanent disability or death among infants and the under-five children, iron supplementation, newborn
screening and breastfeeding. An entry should be made on this list when a delivery is made by pregnant
women on the TCL-PN. Also, include list of eligible newborns and infants from the local birth registration
office and from births that occurred within the community including transferees to have a complete list of
expected number of children.
The updated recording of this list is the responsibility of the midwife in the BHS and the nurse/midwife in the
RHU. A trained BHW or volunteer can also be given the responsibility of recording provided they are under
the supervision of the nurse/midwife.
Column 1 DATE OF REGISTRATION Write in this column the month, day and year an infant was
seen at the clinic or at home for health services.
Column 2 DATE OF BIRTH Write in this column the month, day and year of birth. This column is
important for immunization schedule.
Column 3 FAMILY SERIAL NUMBER Indicate in this column the number that corresponds to the
number of the family folder or envelope or individual treatment record. This column will help
you facilitate retrieval of the clients record.
Column 4 NHTS Write the symbol (*) to indicate that the infant is from the NHTS list provided by the
DSWD
Column 5 NAME OF CHILD Write the complete name of the child.
Column 6 SEX Write the sex of infant; M for male and F for female.
Column 7 COMPLETE NAME OF MOTHER Write in this column the name of the mother (Family
Name, First Name, and Middle Initial)
Column 8 COMPLETE ADDRESS Record the clients permanent place of residence. This column
will help you to monitor or follow-up the client.
Column 9 DATE OF NEWBORN SCREENING This is divided into two sub-columns. The first sub-
column refers to those given with referral only and on the second sub-column refers to
newborn screening done in the health center. Write the date only.
Column 10 CHILD PROTECTED AT BIRTH (CPAB) Write the Tetanus Toxoid Status of the mother in
the sub-column TT STATUS - TT1, TT2, TT3, TT4, TT5 or Fully immunized mother (FIM)
and if the mother received TT2 only, write the month and year TT2 was given. Write the
month and year the child was classified as CPAB.
Column 11 DATE IMMUNIZATION RECEIVED Indicate in these columns the exact date the child
received each antigen or vaccine.
27
FHSIS DIC 201201
Routine Immunization Schedule for Infants
Vaccine Age No. of Reason

Doses
BCG Birth or 1 BCG is given at the earliest
Anytime after birth possible age protects against
the possibility of infection
from other family member
PENTA1 6 weeks 3 An early start with Pentavalent vaccine
PENTA2 10 weeks reduces the chance of
PENTA3 14 weeks severe pertussis, diphtheria,
tetanus, Hepa B and H Influenza
Type B (HIB)
OPV1 6 weeks 3 The extent of protection
OPV2 10 weeks against polio is increased
OPV3 14 weeks the earlier the OPV is given
Hepa B Birth Dose Birth (w/in 24 hrs) 1 Reduces the chance of being
infected and becoming a
carrier of Hepatitis B infection
Measles 9 months 1 At least 85% of measles can
be prevented by
immunization at this age
MMR 12 months 1
ROTA1 6-15 weeks 2

ROTA2 10-32 weeks
Note: Hepa B Birth Dose Write the date and time Hepa B vaccination was given
Rotavirus Vaccine Write the date vaccination was given. In case the child is under immunized or
missed a dose, write not given
Column 12 DATE FULLY IMMUNIZED Write the exact date the child was given the last dose of the
scheduled immunization which makes the child a fully immunized child.
Note: A Fully Immunized Child (FIC) is a child that has received all of the following:
a. One dose of BCG at birth or anytime before reaching 12 months
b. 3 dose each of Pentavalent, OPV and Hepa B as long as the 3rd dose is given before the
child reaches 12 months of age.
c. One dose of anti-measles vaccine before reaching 12 months
Note: If the infant was given the vaccine in other health facilities, ask for the immunization card and write
the date and name of the facility the infant was given the specific dose of the vaccine.
Column 13 CHILD WAS EXCLUSIVELY BREASTFED This column is divided into 6 sub-columns. For
sub-columns 1st to 5th month, put a check if the child was exclusively breastfed while for
sub-column 6th month, write the date if the child was exclusively breastfed.
Column 14 COMPLEMENTARY FEEDING This column is divided into 2 sub-columns. Place a check
if the child was given complementary food at 7th and 8th month.
Column 15 REMARKS Write the reasons why a child failed to return for the
next immunization schedule or why a child reaching 1 year of age was not fully immunized,
to include illnesses, hospitalization, and other data of importance to the child.
28
FHSIS DIC 201201
2.9 Target Client List for Nutrition and Expanded Program for Immunization Part II
Column 1 DATE OF REGISTRATION Write in this column the month, day and year an infant was
seen at the clinic or at home for health services.
Column 2 DATE OF BIRTH Write in this column the month, day and year of birth. This column is
important for immunization schedule.
Column 5 SEX Write the sex of infant; M for male and F for female.
Column 6 COMPLETE NAME OF MOTHER Write in this column the name of the mother (Family
Name, First Name, Middle Initial)
will help you monitor or follow-up the client.
Column 8 MICRONUTRIENT SUPPLEMENTATION This column consists of 3 sub-columns. For

Vitamin A Supplementation column, write the age in months and the date Vitamin A was
received by the infant, and on the Iron column, write the birth weight and date iron was
received by the infant, and on the MNP column write the date MNP was received by the
infant.
Note: Vitamin A received means 1 dose of 100,000 I.U. (one capsule) is given anytime during the 6-11
months. Iron completely received means dosage is 0.3 ml once a day to start at two months of age
until 6 months when complementary foods are given. (Preparation is 15 mg. elemental iron/0.6 ml)
MNP received means 60 sachets is given anytime during 6-11 months and 120 sachets is given
anytime during 12-23 months children.
Micronutrient Supplementation Schedule for Infants
Micronutrient Age No. of Dose Reason

Vitamin A Capsule 6 11 months 1 dose VAC is given starting 6 months to reduce
(100,000 I.U.) child mortality. It also
reduces the severity of the disease
12- 59 months 1 capsule every 6 mos.
Iron 6 - 11 months 15 mg. elemental iron
/0-6 ml once a day for
3 months
Micronutrient 6 11 months 60 sachets over a period o 60 sachets are adequate to rapidly
Powder - Vitamix 6 months improve hemoglobin concentration
and iron stores in a large proportion
=10 sachets/ months of infants.
=30 sachets/ quarter
=60 sachets/ 6 months
Column 9 DEWORMING Put a check if the child was given de-worming tablet.
29
FHSIS DIC 201201
2.10 Target Client List for Sick Children
The Target Client List for Sick Children should include all children under 6 years of age (1) who are
sick with Measles, Severe Pneumonia, persistent Diarrhea, Malnutrition, Xerophthalmia, Night Blindness,
Bitots spots, Corneal Xerosis, Corneal Ulcerations and Keratomalacia and are eligible for Vitamin A
supplementation (2) Anemic children who are eligible for Iron; (3) Children with Diarrhea and (4) Children
with Pneumonia.
The updated recording of this list is the responsibility of the midwife in the BHS and the
nurse/midwife in the RHU. A trained BHW or volunteer can also be given the responsibility of recording
provided they are under the supervision of the nurse/midwife.
Column 1 DATE OF REGISTRATION Indicate in this column the date (month, day and year) the
child was identified to be sick.
Column 4 DATE OF BIRTH Write in this column the month, day and year of birth.
Column 5 SEX Write the sex of infant. M for male and F for female.
help you monitor or follow-up the client.
Column 7 VITAMIN A On the first sub-column, put a check in the column that corresponds to the
following age-group: 6-11 and 12-59 months. For the second sub-column, write the
corresponding code for the diagnosis/findings and on the last column write the date Vitamin
A was given. Use the following codes for diagnosis/findings:
Code Diagnosis/Findings Definition

A Measles History of fever (38C or more) or hot to
touch; and
generalized non-vesicular rash of 3
or more days duration and
at least one of the following: cough,
coryza or conjunctivitis
B Severe Pneumonia Presence of any general danger sign or chest
indrawing or stridor in calm child
C Persistent Diarrhea An episode of soft to watery stools lasting more
than 14 days
D Severely Underweight Children whose weight are classified as very
much lower than normal for his/her age. Has less
than 3 standard deviation.
E Xerophthalmia Used to include all signs and symptoms affecting
the eye that can be attributed to Vitamin A
deficiency. It Includes ocular manifestation of
VAD like nightblindness, conjunctival
xerosis,bitots spots, corneal xerosis, corneal
ulcer/keratomalacia and corneal scar.
30
FHSIS DIC 201201
Is a principal clinical sign of VAD. It is

characterized by changes in the conjunctiva,
which is the membrane that covers the white
area of the eye, leading to Bitots spots.
When the severity of VAD increases, this may be

followed by changes in the cells of the cornea,
which is the part of the eye that covers the iris
and the pupil, and will result in corneal, which is
the part of the eye that covers the iris and the
pupil; and will result in corneal ulcer and
blindness.
F Night Blindness Described as having difficulty in seeing in the
dark, gropes and bumps in furniture and other
objects along the way, asks questions at dusk
like: It is already dark? Where is the door? Some
local names for night blindness are matang-
manok, kurap, harapon, halap.
G Bitots spots These are foamy, soapy, whitish patches seen on

the white part of eye/ sclera conjunctiva).
Frequently associated with nighblindness. It can
be removed but may re-accumulate later. These
patches are caused by the shedding of dead
epithelial cells. It may not disappear completely
after high doses of Vit. A capsule treatment
especially in older children and adults.
H Corneal Xerosis Cornea is cloudy and dry with an orange-peel
appearance. Some people call this fish scale
over the years. Childs vision is diminished even
at daytime
I Corneal Ulcer Cornea becomes soft, bulges with large
perforation or holes in the surface. Children with
prolonged diarrhea and measles frequently
develop this stage. Cornea looks dull and has a
small crater
J Keratomalacia Cornea is soft and no longer flat. It may budge
because of its excessive softness. The cornea is
in danger of rupturing.
K Corneal Scar Cornea has a whitish/ grayish discoloration. This
is due to the healed ulcer or previous VAD.
31
TARGET CLIENT LIST FOR
NUTRITION AND EXPANDED
PROGRAM FOR IMMUNIZATION
MUNICIPALITY OF:
PROVINCE/CITY:
REGION:
FHSIS v. 2012
TCL - N/EPI
TARGET CLIENT LIST FOR NUTRITION AND EPI PROGRAM PART I
DATE OF DATE FAMILY DATE **CHILD PROTECTED
REGISTRA- OF BIRTH SERIAL NHTS* NAME OF CHILD SEX COMPLETE NAME COMPLETE ADDRESS NEWBORN AT BIRTH (CPAB)
TION (mm/dd/yy) NUMBER Y/N OF MOTHER SCREENING (10)
(mm/dd/yy) (9) TT DATE
(1) (2) (3) (4) (5) (6) (7) (8) REFERRAL DONE STATUS ASSESS
NHTS* - to indicate that the infant belongs to the Child Protected at Birth (CPAB)** - refers to a child whose (1) Mother has received 2 doses of TT during this
CCT/NHTS families listed by DSWD. pregnancy, provided TT2 was given at least amonth prior to delivery, or
(2) Mother has received at least 3 doses of TT anytime prior to pregnancy
with this child.
Date Assess - refers to the month and year the child was classified as CPAB based on the definition
39
TARGET CLIENT LIST FOR NUTRITION AND EPI PROGRAM PART I
DATE IMMUNIZATION RECEIVED DATE CHILD WAS EXCLUSIVELY BREASTFED*** COMPLEMENTARY FEEDING REMARKS
ROTA VIRUS
(11) FULLY
VACCINE
(13) (14) (15)
HEPA B1 OPV PENTA PCV MCV IMMUNIZED Put a () check Put a Put a () check
BCG w/in More than MCV1 MCV2 (FIC) *** 1st 2nd 3rd 4th 5th Date 7th 8th
1 2 3 1 2 3 1 2 3 1 2 3
24 HRS 24 HRS (AMV) (MMR) (12) MO MO MO MO MO 6th mo. MO MO
***FULLY IMMUNIZED CHILD = An infant who received 1 dose of BCG, 3 doses each of **** Exclusively breastfed - means no other food (including
OPV, 3 doses each of Pentavalent vaccines and 1 dose water) other than breastmilk. Drops of vitamins and
of Measles-containing vaccine before reaching one year prescribed medication given while breastfeeding is
old. still "exclusively breastfed".
39
FHSIS v. 2012
TARGET CLIENT LIST FOR NUTRITION AND EPI PROGRAM PART II

DATE OF DATE FAMILY MICRONUTRIENT SUPPLEMENTATION DEWORMING
REGISTRA- OF BIRTH SERIAL NAME OF CHILD SEX COMPLETE NAME COMPLETE ADDRESS (8) (9)
TION (mm/dd/yy) NUMBER OF MOTHER VITAMIN A IRON MNP Put a () check
(mm/dd/yy) 6-11 12-59 mos. 2-5 6-11 12-23 24-35 36-47 48-59 6-11 12-23 12-59
(1) (2) (3) (4) (5) (6) (7) MOS. Dose 1 Dose 2 MOS. MOS. MOS. MOS. MOS. MOS. MOS. MOS. MOS.
1
FHSIS DIC 201201
Schedule of High Dose of Vitamin A for High Risk Children
Diagnosis Preparation per Vit. A Dosage & Schedule of

capsule Administration
Measles 100,000 IU for infants Give one capsule upon diagnosis
6-11 months old regardless of when the last dose
200,000 IU for children of vitamin A capsule (VAC) was
12-59 mos. old given. Give another capsule after
24 hrs.
Severe pneumonia, 100,000 IU for infants Give one capsule upon
persistent diarrhea or 6-11 months old diagnosis, except when the child
severely underweight 200,000 IU for children was given VAC less than 4 weeks
12-59 mos. old before diagnosis
Cases with 100,000 IU for infants Give one capsule Immediately

Xerophthalmia,including 6-11 mos old upon diagnosis. Give one
night blindness, Bitots 200,000 IU for children capsule the next day, and another
spots, corneal xerosis, 12-59 mos. old 1 capsule 2 weeks after.
corneal ulcerations,
and keratomalacia
COLUMN 8 ANEMIC CHILDREN GIVEN IRON SUPPLEMENTATION On the first column, write
the age in months of the sick children followed by the date started iron and date
completed.
COLUMN 9 DIARRHEA CASES Write the age in months of the sick children followed by the dates
ORT, ORS and ORS with zinc was given.
COLUMN 10 PNEUMONIA CASES Write the age in months of the sick children followed by the
date antibiotic treatment was given.
COLUMN 11 REMARKS Write other data of importance to child care.
32
TARGET CLIENT LIST FOR
SICK CHILDREN
MUNICIPALITY OF:
PROVINCE/CITY:
REGION:
FHSIS v. 2012
TCL- SICK 2.10 TARGET CLIENT LIST FOR SICK CHILDREN

DATE OF FAMILY DATE VITAMIN A SUPPLEMENTATION
REGIS- SERIAL NAME OF CHILD OF BIRTH SEX COMPLETE ADDRESS (7)
TRATION NUMBER (mm/dd/yy) Put a () check DIAGNOSIS/ DATE
mm/dd/yy 6-11 12-59 FINDINGS* GIVEN**
(1) (2) (3) (4) (5) (6) MOS. MOS. (use code)
* Diagnosis/Findings : ** Recommended Vitamin A Supplementation Given to High Risk/Sick Children

A = Measles H = Corneal Xerosis DIAGNOSIS PREPARATION PER CAPSULE VIT. A DOSAGE AND SCHEDULE OF ADMINISTRATION
Give one capsule upon diagnosis regardless of when the
B = Severe Pneumonia I = Corneal Ulcerations Measles cases 100,000 IU for infants 6-11 months old last dose of vitamin A capsule (VAC) was given.
C = Persistent Diarrhea J = Keratomalacia Give another capsule after 24 hours
D = Malnutrition Severe pneumonia, persistent diarrhea 200,000 IU for children 12-59 months old Give one capsule upon diagnosis, except when the child
E = Xerophthalmia and severely underweight 100,000 IU for infants 6-11 months old was given VAC less than 4 weeks before diagnosis
F = Night Blindness Cases with Xerophthalmia,incldg night 200,000 IU for children 12-59 months old Give one capsule immediately upon diagnosis. Give one
G = Bitot's spots blindness, Bitot's spots, corneal xerosis, 100,000 IU for infants 6-11 months old capsule the next day, and 1 capsule 2 weeks after.
corneal ulcerations and keratomalacia 200,000 IU for infants 12-59 months old
35
TARGET CLIENT LIST FOR SICK CHILDREN
ANEMIC CHILDREN GIVEN DIARRHEA CASES PNEUMONIA CASES
IRON SUPPLEMENTATION*** (6- 59 months) (9) SEEN REMARKS
(8) AGE IN DATE GIVEN (10)
AGE IN MONTHS DATE MONTHS ORS/ORT W/ AGE IN DATE GIVEN
ORS
6-11 mos 12-59 mos STARTED COMPLETED ZINC MONTHS TREATMENT (11)
* ** Iron Supplementation : Dosage is 1 tsp once a day for 3 months or

30 mg once a week for 6 months with supervised administration
DIAGNOSIS PREPARATION DOSAGE AND SCHEDULE OF ADMMINISTRATION
note: after completing 3 mos therapeutic
low birth weight infants (<2.5kg) drops 15 mg elemental iron/0.6 ml give 0.3 ml once a day starting at 2 mos up to 6 mos supplementation infants should continue
preventive supplementation regimen or
: give approximately 0.6ml 2-3 times a day for 3
mos
6-11 mos old clinically diagnosed with Iron Deficiency Anemia (IDA) drops 15 mg elemental iron/0.6 ml give 3-6 mg/Kg/day elemental Iron in 3 divided doses a day for 3 mos
give approximately 5ml 2-3 times a day for 3 mos. If available, continue
12-23 mos clinically diagnosed with Iron Deficiency Anemia (IDA) syrup 30 mg elemental Iron/5ml MNP supplementation after 3 mos
give approximately 5ml 2-3 times a day for 3 mos. If available, continue
MNP supplementation after 3 mos. Assess children after 3 mos for
12-59 mos clinically diagnosed with Iron Deficiency Anemia (IDA) syrup 30 mg elemental Iron/5ml further management
35
FHSIS DIC 201201
2.11 SUMMARY TABLES:
The Summary Tables are intended to record data in the facility to facilitate the capture and
recall of data.
2.11.1 Summary Table Health Program Accomplishments
The Summary Table Health Program Accomplishments is a health facility-based document

which records the performance of the barangay per month for one year, is filled up by the midwife,
and is her source of data for the Monthly Form. The table has provision for quarterly totals which
should be equivalent to the quarterly total of the PHN in her Consolidation Table. The quarterly totals
are also provided in this Summary Table so that the midwife can already make preliminary analysis of
her performance using these data.
Filling up the table
The first column lists exhaustively the indicators of your health service delivery in the barangay.
The next column is the Target column where you will place, at the start of the year, the targets of your
barangay for each Indicator. Please consult your PHN for the figure you will enter in this column.
Under each succeeding monthly columns, record the number being asked that corresponds to each
indicator for the month. Under each quarter, write the totals required.
2.11.2 Summary Table - Morbidity Report
The Summary Table Morbidity Report records all the diseases that occur for the entire year.
The diseases are recorded on a monthly basis disaggregated by age group and sex. This Summary
Table shall also be the source of data for the Annual Report 2 Morbidity Report.
Filling up the table
On the Summary Table Monthly Morbidity, write on the space provided the month, the name
of disease and the number of cases per disease disaggregated by age group and sex.
2.12 MONTHLY CONSOLIDATION TABLE:
Monthly Consolidation Table - is a health facility-based document in which the PHN records the
report of the midwives in the municipality. At the end of every quarter, the PHN gets the totals of the
different indicators to fill-up the Quarterly form for submission to the PHO.
The month and year which corresponds to the Monthly Report of each Barangay. The first
column lists the indicators/diseases in the Monthly Form. On the succeeding column, write the name of
each BHS on top and the corresponding monthly data of each BHS.
40
Summary Table
for
BARANGAY
NAME OF BARANGAY:
NAME OF HEALTH CENTER:
MUNICIPALITY OF:
PROVINCE/CITY:
REGION:
2.13.1 MATERNAL CARE - PRENATAL and POSTPARTUM CARE
INDICATORS TARGET JAN FEB MAR 1st Q APR MAY JUNE 2nd Q JULY AUG SEPT 3rd Q OCT NOV DEC 4th Q TOTAL
PRENATAL CARE
1. Pregnant women with 4 or

more prenatal visits
2. Pregnant women given
2 doses of TT
TT2 plus
complete iron with folic acid
5. Pregnant given Vit. A
POSTPARTUM CARE
1. Postpartum women with
at least 2 PPV
2. Postpartum women
given complete iron
3. 10-49 years old women given

Iron supplementation
4. Postpartum women
given Vitamin A
5. Postapartum women
initiated breastfeeding
STI SURVEILLANCE
1. No. of pregnant women seen
2. No. of pregnant women
tested for syphilis
positive for syphilis
4. No. of pregnant women (+)
for syphilis given Penicillin
51
2.13.2 FAMILY PLANNING (Part 1 of 2)
1. Total New Acceptors

Female Sterilization
Male Sterilization
Pills
IUD
Injectables (DMPA/CIC)
NFP-CM
NFP-BBT
NFP-LAM
NFP-SDM
NFP-STM
Condom
Implant
2. Total Other Acceptors
Male Sterilization
Pills
IUD
NFP-CM
NFP-BBT
NFP-LAM
NFP-SDM
NFP-STM
Condom
Implant
38
2.14.3 FAMILY PLANNING (Part 2 of 2)
3. Total Drop-out
Male Sterilization
Pills
IUD
NFP-CM
NFP-BBT
NFP-LAM
NFP-SDM
NFP-STM
Condom
Implant
4. Total Current Users
Male Sterilization
Pills
IUD
NFP-CM
NFP-BBT
NFP-LAM
NFP-SDM
NFP-STM
Condom
Implant
62
2.13.4 CHILD CARE (Part 1 of 3)
JAN FEB MAR 1st Q APR MAY JUN 2nd Q JUL AUG SEPT 3rdQ OCT NOV DEC 4thQ TOTAL
INDICATORS TARGET
M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F
1. Immunization given <1 yr
BCG
w/in 24 hrs
Hepa B1
> 24 hrs
PENTA 2
OPV 2
MCV1 (AMV)
MCV
MCV2 (MMR)
ROTA 2
PCV 2
2. Fully Immunized Child
3. Completely Immunized
Child (12-23 mos)
4. Child Protected at Birth (CPAB)
59
INDICATORS TARGET
5. Infant age 6 mo. seen

6. Infant exclusively
breastfed until 6 mo.
7. Infants 6-8 months of age who
received solid, semi-solid and
soft food during previous day
8. Infant for newborn screening
referred
done
9. Infant/Children received Vit. A
6-11 mos.
12-23 mos.
24-35 mos.
36-47 mos.
48-59 mos.
10. Infant/Children received Iron
2-5 mos.
6-11 mos.
12-23 mos.
24-35 mos.
36-47 mos.
48-59 mos.
11. Infant/Children received MNP
6-11 mos.
12-23 mos.
12. Sick Children seen
6-11 mos.
12-59 mos.
13. Sick Children received Vit A
6-11 mos.
12-59 mos.
58
INDICATORS TARGET
14. Children 12-59 mos. old
given de-worming tablet/syrup
15. Infant 2-6 mos. w/ LBW seen
received full dose Iron
16. Anemic infant
6-11 mos seen
Anemic children
12-59 mos seen
17. Diarrhea (0-59 mos. old)
No. of Cases
received ORS
received ORT/ORS w/zinc
18. Pneumonia (0-59 mos. old)
No. of Cases
No with Completed Treatment
57
2.13.7 DENTAL HEALTH
INDICATORS TARGET
1. Orally Fit Child
12-71 mos. old
2. Child 12-71 mos
provided w/BOHC
3. Adolescent & Youth
(10-24 yo)given
BOHC
4. Preg women
provided w/BOHC
5. Older Person
60 yrs old & above
provided w/BOHC
56
2.13.8 MALARIA
INDICATORS
M F T M F T M F T M F T M F T M F T M F T M F T M F T M F T M F T M F T M F T M F T M F T M F T M F T
1.Total Population
2. Population at risk
3.Annual Parasite
Incidence
4. Total No. of
Confirmed Malaria
Cases
< 5 yo
5 yo
Pregnant
5. Total No of Lab
Confirmed Malaria
Cases by species
P.falciparum
P. vivax
P.ovale
P.malariae
6. Total No of
Confirmed Malaria
Cases by method
Slide
RDT
7. Total No. of LLIN
given
8. Total No. of
Malaria Deaths
45
2.13.9 TUBERCULOSIS
1st Q 2nd Q 3rdQ 4thQ TOTAL
INDICATORS
M F T M F T M F T M F T M F T
1. TB symptomatics who
underwent DSSM
2. Smear positive
discovered and identified
3. New smear positive

cases initiated tx and
registered
4. New smear (+) cases
cured
5. Smear(+) retreatment
cases cured
6. Smear (+) retreatment
cases initiated tx and
registered
Relapse
Treatment failure
Return after default
Other type of TB
7. No, of Smear (+)
retreatment cured
Relapse
Treatment failure

8.. Total No. of TB cases
(all forms) initiated tx
47
2.13.10 FILARIASIS
INDICATORS
Total Population
1.No. Cases with
hydrocele, lymphedema,
Elephantiasis, Chyluria
2. Clinical Rate
3. No of Cases examined
found Positive for MF
5. Average MFD
6. Eligible population given
MDA (94.6% of TP)
7. Total population given

MDA
43
2.13.11 LEPROSY
INDICATORS
1. Total Population
2. Total No. of Leprosy
cases (undergoing TXT)
3. No. of Newly detected
Leprosy cases
< 15 yo
Grade 2 disability
4. No of Leprosy Cases
cured
46
2.13.12 SCHISTOSOMIASIS
INDICATORS
1. No. of
Symptomatic case
2. No. of Cases
Examined
3. No. of Positive
Cases
Low intensity
Medium intensity
High intensity
4. No. of Cases
treated
5. No of Complicated
Cases
6. No. of Complicated
Cases referred to
hospital facility
44
2.13.13 MORBIDITY DISEASE REPORT FOR MONTH: ____________
NAME BY AGE-GROUP AND BY SEX
OF ICD Code Under 1 1-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70 & over TOTAL
DISEASE M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F
Acute Watery Diarrhea A09 (watery)

Acute Bloody Diarrhea A09 (bloody)
Inluenza-like Illness J11
Influenza J11
Acute Flaccid Paralysis G83.9
Acute Hemorrhagic Fever Syndrome (Dengue) A91
Acute Lower Respiratory Track Infection J22
Pneumonia J18.9
Cholera A00
Diphtheria A36
Filarisis B74
Leprosy A30
Leptospirosis A27
Malaria B50-B54
Measles B05
Meningococcemia A39
Neonatal Tetanus A33
Non-neonatal Tetanus A35
Paralytic Shellfish Poinosning T61.2
Rabies A82
Schistosomiasis B65
Typhoid and paratyphoid A01
Viral Encephalitis A83-86
Acute Viral Hepatitis B15-B17
Viral Meningitis A87
Syphilis A50-A53
Gonorrhea A54.9
Urethral Discharge R36
Genital Ulcer N48.5, N76.5, N76.6
61
2.13.14 MORBIDITY DISEASE REPORT FOR MONTH: ____________
OF Under 1 1-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70 & over TOTAL
60
2.13.15 NATALITY (from TCL) (Part 1 of 2)
INDICATORS TARGET
1. Livebirths (Total from
TCL)
2. Birthweight:
2500 grms &

greater
Less than
2500 grams
Not known
3. Attended by:
Doctors
Nurses
Midwives
Trained Hilot
Others
Unknown
55
2.13.16 NATALITY (from TCL) (Part 2 of 2)
INDICATORS TARGET
Total No. of
Deliveries
by Place
Health Facility
RHUs
Hospitals
BHS
lying-in
NID
Home
Others
by Type
Normal
Others
Total Number of
Pregnancy
by Outcome
Livebirth
Fetal Death
Abortion
53
2.13.17 NATALITY (from LCR) (Part 1 of 2)
INDICATORS TARGET
1. Livebirths (Total from
TCL)
2. Birthweight:
2500 grms &

greater
Less than
2500 grams
Not known
3. Attended by:
Doctors
Nurses
Midwives
Trained Hilot
Others
Unknown
54
2.13.18 NATALITY (from LCR) (Part 2 of 2)
INDICATORS TARGET
4. Normal Delivery
Home
Hospital
Others
5. Other Type Delivery
Home
Hospital
Others
52
2.13.19 ENVIRONMENTAL HEALTH
1. Households with access

to improved water
Level I
Level II
Level III
2. HH w/sanitary toilet
3. HH w/satisfactory
disposal of solid waste
4. HH w/complete basic
sanitation facilities
5. Food Establishment
6. Food Establishment w/
sanitary permit
7. Food Handlers
8. Food Handlers with
health certificates
9. Salt Samples Tested
10. Salt Samples Tested
found (+) for iodine

50
2.13.20 MORTALITY (From LCR or RHU log books)
INDICATORS TARGET
1. Total Deaths
2. Infant Deaths
3. Maternal Deaths
4. Neonatal Deaths
5. Deaths due to
neonatal tetanus
6. Pernatal Deaths
7. Deaths among
child under 5 yo
48
2.13.21 PROGRAM: ______________________________
ACTIVITIES TARGET
49
Monthly Consolidation Table
for
HEALTH CENTER
NAME OF HEALTH CENTER:
MUNICIPALITY OF:
PROVINCE/CITY:
REGION:
2.14.1 MATERNAL CARE Month: ___________ __ Year: ___________________
N A M E OF B A R A N G A Y
INDICATORS
1. Pregnant women
W/4 or more prenatal visits

Given 2 doses of TT
Given TT2plus
Given complete iron with

folic acid
Given Vitamin A
2. Postpartum women
With at least 2 PPV
Given complete iron
10-49 years old women
given Iron supplementation
Given Vitamin A
Initiated Breastfeeding

tested for SY
positive for SY
given Penicillin
75
Month: _____________ Year: ___________________
Total
2.14.2 FAMILY PLANNING (Part 1 of 4) Month: _____________ Year: ___________________
INDICATORS
Female Ster/BTL
Male Ster/Vasectomy
Pills
IUD
NFP-CM
NFP-BBT
NFP-STM
NFP-SDM
NFP-LAM
Condom
Implant
74
Month: _____________ Year: ___________________
Total
INDICATORS
Female Ster/BTL
Male Ster/Vasectomy
Pills
IUD
NFP-CM
NFP-BBT
NFP-STM
NFP-SDM
NFP-LAM
Condom
Implant
Month: _____________ Year: ___________________
Total
INDICATORS
3. Drop-out
Female Ster/BTL
Male Ster/Vasectomy
Pills
IUD
NFP-CM
NFP-BBT
NFP-STM
NFP-SDM
NFP-LAM
Condom
Implant
73
Month: _____________ Year: ___________________
Total
INDICATORS
4. Total Current Users
Female Ster/BTL
Male Ster/Vasectomy
Pills
IUD
NFP-CM
NFP-BBT
NFP-STM
NFP-SDM
NFP-LAM
Condom
Implant
72
Month: _____________ Year: ___________________
Total
2.14.5 CHILD CARE (Part 1 of 3) Month: _____________ Year: ___________________
INDICATORS
1. Immunization given <1 yr:
BCG
w/in 24 hrs
Hepa B1
> 24 hrs
1
PENTA 2
3
1
OPV 2
3
MCV1 (AMV)
MCV
MCV2 (MMR)
1
ROTA 2
3
1
PCV 2
3
2. Fully Immunized Child
3. Completely Immunized Child (12-23 mos)

4. Child Protected at Birth (CPAB)
69
Month: _____________ Year: ___________________
Total
M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F
2.14.6 CHILD CARE (Part 2 of 3) Month: ___________ __ Year: ___________________
INDICATORS
5. Infant age 6 mos. Seen
6. Infant exclusively breastfed
until 6 months
7. Infants 6-8 months of age who
received solid, semi-solid and soft
food during previous day
8. Infant referred for
newborn screening
9. Infant/Children received Vit. A
6-11 mos.
12-23 mos.
24-35 mos.
36-47 mos.
48-59 mos.
10. Infant/Children received Iron
2-5 mos.
6-11 mos.
12-23 mos.
24-35 mos.
36-47 mos.
48-59 mos.
11. Infant/Children consumed MNP
6-11 mos.
12-23 mos.
12. Sick Children seen
6-11 mos.
12-59 mos.
13. Sick Children received Vit. A
6-11 mos.
12-59 mos.
68
Month: _____________ Year: ___________________
Total
2.14.7 CHILD CARE (Part 3 of 3) Month: _____________ Year: ___________________
INDICATORS
14. Children 12-59 mos. old
given de-worming tablet
15. Infant 2-6 mos. w/ LBW seen
16. Anemic Children
6-11 mos seen
Anemic children
12-59 mos seen
17. Diarrhea (0-59 mos. old)
No. of Cases
received ORS
received ORS/ORT w/zinc
18. Pneumonia (0-59 mos. old)

No. of Cases
No with Completed Treatment
67
Month: _____________ Year: ___________________
Total
2.14.8 LEPROSY Month:___________________________ Year: ___________________
INDICATORS
1. Total Population
2. Total No. of Leprosy cases

(undergoing treatment)
Leprosy cases
< 15 yo
Grade 2 disability
4. No of Leprosy Cases cured
90
Month:___________________________ Year: ___________________
Total
91
2.14.9 TUBERCULOSIS Month:___________________________ Year: ___________________
INDICATORS
1. TB symptomatics who
underwent DSSM
2. Smear positive discovered

and identified
3. New smear positive cases

initiated tx and registered
4. New smear (+) cases cured
5. Smear(+) retreatment cases

cured
6. Smear (+) retreatment cases

initiated tx and registered
Relapse
Treatment failure
Other type of TB
7. No, of Smear (+)
retreatment cured
Relapse
Treatment failure
8.. Total No. of TB cases (all
forms) initiated treatment
9. TB All forms identified
10. Case Detection Rate
88
Month:___________________________ Year: ___________________
Total
M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F
89
2.14.10 MALARIA Month:___________________________ Year: ___________________
INDICATORS
1.Total Population
2. Population at risk
3.Annual Parasite Incidence

4. Total No. of Confirmed
Malaria Cases
< 5 yo
5 yo
5. Total No. of Confirmed
Malaria Cases
Pregnant
6. Total No of Lab Confirmed

Malaria Cases by species
P.falciparum
P. vivax
P.ovale
P.malariae
7. Total No of Confirmed
Malaria Cases by method
Slide
RDT
8. Total No. of LLIN given
9. Total No. of Malaria Deaths
86
Month:___________________________ Year: ___________________
Total
2.14.11 FILARIASIS Month:___________________________ Year: ___________________
INDICATORS
1.No. Cases with hydrocele,

lymphedema, Elephantiasis,
Chyluria
2. Clinical Rate
3. No of Case examined
found Positive for MF
5. Average MFD
6. Eligible population given

MDA (94.6% of TP)
7. Total population given MDA
84
Month:___________________________ Year: ___________________
Total
85
2.14.12 SCHISTOSOMIASIS Month:___________________________ Year: ___________________
INDICATORS
1. No. of Symptomatic case
2. No. of Cases Examined
3. No. of Positive Cases
Low intensity
Medium intensity
High intensity
4. No. of Cases treated
5. No of Complicated Cases
6. No. of Complicated Cases
referred
82
Month:___________________________ Year: ___________________
Total
83
2.14.13 DISEASE: ________________________________ Month:___________________________ Year: ___________________
AGE GROUP
Under 1 year
1-4
5 -9
10 - 14
15 - 19
20 - 24
25 - 29
30 - 34
35 - 39
40 - 44
45 - 49
50 - 54
55 - 59
60 - 64
65 - 69
70 and 0ver
TOTAL
81
Month:___________________________ Year: ___________________
Total
83
2.14.14 PROGRAM: __________________________________
ACTIVITIES
80
FHSIS DIC 201201

2.15THEMONTHLYFORMFORPROGRAMREPORT(M1):
TheMonthlyFormisthereportingformthatthemidwifefillsuptoreportheraccomplishments
from the first day to the last day of the month and submits to the nurse at the RHU/MHC for
consolidation.Spacesareleftblankforthoseindicatorsthemunicipality/cityneedstogenerateattheir
level.
HeadingFillupthedataaskedforintheheading:theMonthbeingreportedandtheYear,thenameof
the Barangay, Name of BHS, the Municipality or City, Province and the Projected Population of the
Barangay(exceptduringNationalCensusyears).

2.15.1MaternalCare
Deliverieswriteonthespaceprovidedthetotalnumberofdeliveries
Pregnant women with 4 or more prenatal visits write on the space provided the total number of
pregnantwomenwhohad4ormoreprenatalvisitsduringthemonth/quartersuchthatatleast
onevisitoccursduringthefirsttrimester,oneduringthesecondtrimesterandatleast2visits
duringthethirdtrimester.

Pregnantwomengiven2dosesofTetanusToxoidwriteonthespaceprovidedthetotalnumberof
pregnantwomengiven2dosesofTetanusToxoidduringthemonth/quarter.
PregnantwomengivenTT2pluswriteonthespaceprovidedthetotalnumberofpregnantwomen
givenTT2plusduringthemonth/quarter.TT2plusincludes2nd,3rd,4thand5thdosesofTetanus
Toxoidgiventopregnantwomen.
Pregnantwomengivencompleteironwithfolicacidsupplementationwriteonthespaceprovided
thetotalnumberofpregnantwomengivencompletetabletof60mgofFewith400mcgFolic
acid,onceadayfor6monthsor180tablets.Theirontabletsreferredto,arethosegivenfor
freetothemotherbytheRHUsandBHSsanddonotincludeprescribedirontablets.Irontablet
shouldbegivenassoonaspregnancywasdiagnosed.Ifthepregnantwomendidnottakefull
courseofthe180tablets,shewillnotbeincludedinthereport.

Postpartumwomenwithatleast2postpartumvisitswriteonthespaceprovidedthetotalnumber
ofpostpartumwomenwhowereseenbythemidwife/PHN/MHOathomeorattheclinictwice
ormorethantwiceafterdeliverysuchthatfirstvisitshouldbewithin24hoursupondelivery
andthesecondvisitwithinoneweekafterdelivery.
Post partum women given completeiron supplementation writeon the spaceprovided the total
numberofpostpartumwomengivencompletetabletof60mcgofFewith400mcgFolicacid,
onceadayfor3monthsoratotalof90tablets.Ifpostpartummotherdidnottakefullcourseof
90tablets,shewillnotbeincludedinthereport.
1049yearsoldwomengivenIronsupplementationwriteonthespaceprovidedthetotalnumberof
womengivenIronsupplementation

PostpartumwomengivenVitaminAsupplementationwriteonthespaceprovidedthetotalnumber
ofpostpartumorlactatingwomengiven200,000I.U.ofVitaminAcapsulewithin4weeksafter
delivery

Post partum women initiated breastfeeding within 1 hour after delivery write on the space
provided the total number of postpartum or lactating women who initiated breastfeeding
within1houraftergivingbirth.
92
FHSIS DIC 201201

2.15.2STISurveillance
Numberofpregnantwomenwriteonthespaceprovidedthetotalnumberofpregnantwomenseen
inthehealthcenter.
NumberofpregnantwomentestedforSyphilis(SY)writeonthespaceprovidedthetotalnumberof
pregnantwomentestedforSyphilis.

NumberofpregnantwomenpositiveforSyphiliswriteonthespaceprovidedthetotalnumberof
pregnantwomentestedpositiveforSyphilis.
Number of pregnant women with Syphilis given Penicillin write on the space provided the total
numberofpregnantwomenwithSyphilisgivenPenicillin.
2.15.3FamilyPlanning

Current Users (Beginning Month) write on the space provided the total number of FP clients who
havebeencarriedoverfromthepreviousmonth

Acceptors

NewAcceptorsofpreviousmonthwriteonthespaceprovidedthenumberofnewacceptors
frompreviousmonth.
OtherAcceptorsofpresentmonthwriteonthespaceprovidedthenumberofclientswhoare
ChangedMethod,ChangedClinicandRestart.

Dropouts(presentmonth)writeonthespaceprovidedthenumberofclientswhodropoutduring
themonth.

Current Users (End Month) write on the space provided the total number of FP clients who have
beencarriedoverfromthepreviousmonthafterdeductingthedropoutsofthepresentmonth,
adding the new acceptors of the previous month and adding the other acceptors (RS,CC,CM).
This consists of CU for pills, IUD, injectables, condom, NFP (BBT, CM, STM, SDM and LAM),
femalesterilization,malesterilizationandimplants.
(Note:Inpreparingthemonthlyreportforthisportion,themidwifeintheBHS/Barangaywill
preparethemonthlydataonly.)Memotobepasted

CalculationsampleforMonthofFebruaryReport:

Currentusersfromthepreviousmonth (Jan2012) 29
+NewAcceptorspreviousmonth (Jan2012) +6
+OtherAcceptorsofthepresentmonth (Feb2012) +4
Dropoutspresentmonth (Feb2012)2
=CurrentUsersendingmonthofFeb2012 =37

*SeeAnnex1fortheCalculationoftheCurrentUsers
93
FHSIS DIC 201201
NewAcceptorsofthepresentmonthusingafamilyplanningmethodforthefirsttimeoraclient
whohasneveracceptedanymodernfamilyplanningmethodatanyclinicsbefore(newtothe
program). It includes new acceptors for pills, IUD, injectables, condom, NFP (BBT, CM, STM,
andSDM),LAM,implants,FemaleSTRandMaleSTR.

2.15.4ChildCare

Immunization by antigen (BCG, PENTA1to PENTA3, OPV1 toOPV3, Hepatitis birth dose within 24
hours after birth or after 24 hours after birth, ROTA1 to ROTA3, antiMeasles vaccine and
measlesmumpsrubella(MMR))writeonthespaceprovidedthetotalnumberofinfants011
monthswhoweregiventhespecificantigenduringthemonth/quarter.
FullyImmunizedChildwriteonthespaceprovidedthetotalnumberofchildren011monthsthat
havecompletedtheirimmunizationscheduleduringthemonth/quarter.Tobefullyimmunized,
thechildmusthavebeengivenBCG,3dosesofPENTA,3dosesofOPV,1doseofHepaBBirth
doseandonedoseofantimeaslesvaccinebeforereaching1yearofage.Thechildiscounted
as FIC as soon as all the required vaccines are administered without waiting for the child to
reach1yearofage.
CompletelyImmunizedChild(1223mos.)writeonthespaceprovidedthetotalnumberofchildren
1223 months of age who completed their immunization schedule during the month/quarter.
Tobecompletelyimmunized,thechildmusthavebeengivenBCG,3dosesofPENTA,3dosesof
OPV,1doseofHepaBBirthdose,onedoseeachofantimeaslesvaccineandMMR.
ChildProtectedatBirth(CPAB)writeonthespaceprovidedthetotalnumberofchildrenwhose(1)
Mother has received 2 doses of TT during this pregnancy, provided TT2 was given at least a
month prior to delivery, or (2) Mother has received at least 3 doses of TT anytime prior to
pregnancy with this child. If the mother received TT2 only for this child, write the month and
yearTT2wasgiven.
Infants 6 months of age seen write on the space provided the total number of infants seen at 6th
monthatthefacilityorduringhomevisit.
Infantsexclusivelybreastfeduntil6monthswriteonthespaceprovidedthetotalnumberofinfants
seentobeexclusivelybreastfedfrombirthupto6thmonths.Exclusivelybreastfeedingisgiving
no other food (including water) other than breast milk. Drops of vitamins and prescribed
medication(bydoctoronly)givenwhilebreastfeedingisstillexclusiveBF.
Infants given complimentary food 68 months write on the space provided the total number of
infantsgivencomplimentaryfoodfrom68monthsofage.
Infantreferredfornewbornscreeningwriteonthespaceprovidedthetotalnumberofinfantsgiven
referralfornewbornscreening.
Infant611monthsoldgivenVitaminAwriteonthespaceprovidedthetotalnumberofinfants611
monthsoldgivenVitaminASupplementation.VitaminAsupplementationrefersto1doseof
100,000I.U.Onecapsuleisgivenanytimeduringthe611months.
Children1223,2435,3647,and4859monthsoldgivenVitaminAwriteonthespaceprovidedthe
total number of children 1259 months old given Vitamin A Supplementation. Vitamin A
supplementationrefersto200,000I.U.Dosageanddurationis1capsuleeverysixmonths.
Infant25and611monthsoldgivenIronwriteonthespaceprovidedthetotalnumberofinfants
givenIronSupplement.
94
FHSIS DIC 201201
Children1223,2435,3647,and4859monthsoldgivenIronwriteonthespaceprovidedthetotal
numberofchildrengivenIronSupplement.
Infants611monthsoldreceivedMNPwriteonthespaceprovidedthenumberofinfantswhoseages
rangefrom6to59monthsreceivedMNP.60sachetsweregivenanytimeduring611months.
Children1223monthsoldreceivedMNPwriteonthespaceprovidedthenumberofchildrenwhose
agesrangefrom12to23monthsreceivedMNP.120sachetsweregivenanytimeduring1223
monthschildren
Children1259mos.oldgivendewormingtabletwriteonthespaceprovidedthenumberofchildren
whoseagesrangefrom12to59monthsreceiveddewormingtablet.
Sick Children 611 and 1259 months old seen write on the space provided the number of sick
children whose ages range from 6 to 11 months and 1259 months old seen during the
month/quarter. High Risk or Sick Children are those with the following categories: (1) severe
pneumonia (2) persistent diarrhea (3) measles (4) severely under weight and (5) Cases with
Xerophthalmia, including night blindness, Bitots spots, corneal xerosis, corneal ulcerations,
keratomalaciaandcornealscar.
Sick Children 611 months old given Vitamin A Write on the space provided the number of sick
children whose age range from 6 to 11 months and were given Vitamin A during the
month/quarter.DosageofVitaminAfor611monthsoldinfantsis100,000IU.
NOTE:VitaminAgivenduringGarantisadongPambatashouldnotbeincludedinthisreport.

Sick Children 1259 months old given Vitamin A write on the space provided the number of sick
childrenwhoseagesrangefrom12to59monthsoldandweregivenVitaminAcapsuleduring
themonth.DosageofVitaminAfor1259monthsoldchildrenis200,000IU(1capsuleevery6
months).NOTE:VitaminAgivenduringGarantisadongPambatashouldnotbeincludedinthis
report.

Infant 26months old with low birth weight write on the spaceprovided the number of infant
whoseagesrangefrom2to6monthsoldwithlowbirthweightseenduringthemonth/quarter.
Lowbirthweight(LBW)Infantreferstoinfantwithbirthweightlessthan2.5kilogramsor2,500
grams.
Infant26monthsoldwithlowbirthweightgivenironsupplementswriteonthespaceprovidedthe
numberofinfantswhoseagesrangefrom2to6monthsoldwithlowbirthweightandwasgiven
ironduringthemonth/quarter.Dosageis0.3mlonceadaytostartattwomonthsofageuntil6
monthswhencomplementaryfoodsaregiven.(Preparationis15mg.elementaliron/0.6ml).
AnemicChildren611monthsand1259monthsoldseenwriteonthespaceprovidedthenumberof
anemicchildrenwhoseagesrangefrom2to59monthsoldseenduringthemonth/quarter.6
11monthsdrops1259monthssyrup/MNP
AnemicChildren611monthsand1259monthsoldseengivenironsupplementswriteonthespace
provided thenumber of anemic childrenwhose ages range from 2 to 59 months old and was
givenironsupplementationduringthemonth/quarter.Dosageis1tsp.onceadayfor3months
or30mg.onceaweekfor6monthswithsupervisedadministration.
Diarrhea cases 059 months old seen write on the space provided the total number of diarrhea
children059monthsoldseenduringthemonth/quarter.
Diarrheacases059monthsoldgivenORSwriteonthespaceprovidedthetotalnumberofdiarrhea
children whose ages range from 0 to 59 months old and was given ORS during the
month/quarter.
95
FHSIS DIC 201201
Diarrhea cases 059 months old given ORS/ORT with zinc write on the space provided the total
numberofdiarrheachildrenwhoseagesrangefrom0to59monthsoldandwasgivenORSwith
zinc during the month/quarter. Dosage for children less than 6 months is 10 mg. elemental
Zn/dayandforchildrenmorethan6monthsis20mgelementalZn/dayx1014days.

Pneumoniacases059monthsoldseenwriteonthespaceprovidedthetotalnumberofchildren0
59monthsoldseenwithpneumoniaduringthemonth/quarter.
Pneumoniacases059monthsoldgiventreatmentwriteonthespaceprovidedthetotalnumberof
children059monthsoldseenwithpneumoniaandwasgivenantibiotictreatmentduringthe
month/quarter.
2.15.5Malaria

Malariacaseamonglessthan5yearsofageandabove5yearsofagewriteonthespaceprovided
thetotalnumberofmalariacasesamonglessthan5yearsofageandabove5yearsofage.
LaboratoryConfirmedmalariacasesbyspecies:P.falciparum,P.vivax,P.malariae,P.ovalewrite
on the space provided the total number of malaria cases by species by sex and pregnant
women.(P.falciparum,P.vivax,P.malariae,P.ovale).Incolumn1,writethetotalnumberofmale
clientsconfirmedpositiveofmalaria(P.falciparum,P.vivax,P.malariae,P.ovale).Incolumn2,
writethetotalnumberoffemaleclientsconfirmedpositiveofmalariaexcludingpregnantwomen
(P. falciparum, P. vivax, P. malariae, P. ovale). While in column 3, write the total number of
pregnantwomenpositiveofmalaria(P.falciparum,P.vivax,P.malariae,P.ovale).(SeeAnnex2.9
ITRMalariaPreventionandControlProgram)
Confirmed malaria cases by method: Slide and Rapid Diagnostic Test (RDT) write on the space
provided the total number of malaria cases by method (slide and RDT). (See Annex 2.9 ITR
MalariaPreventionandControlProgram)
Householdsatriskwriteonthespaceprovidedthetotalnumberofhouseholdsatriskofmalaria.
HouseholdsgivenLongLastingInsecticideNets(LLIN)writeonthespaceprovidedthetotalnumber
ofhouseholdsgivenlonglastinginsecticidenets.
2.15.6Tuberculosis
TB symptomatics who underwent Direct Sputum Smear Microscopy (DSSM) write on the space
provided the total number of person who present symptoms or signs suggestive of TB, in
particular cough or long duration (2 or more weeks of cough). In this column, write the total
numberofpersonswithTBsymptomaticswhounderwentDSSMregardlessoftheresults.(See
Annex2.8ITRTuberculosisPreventionandControlProgram)
Smearpositive(+)discoveredwriteonthespaceprovidedthenumberofpatientwiththefollowing:
(SeeAnnex2.8ITRTuberculosisPreventionandControlProgram)

1. atleast2sputumspecimenspositiveforAcidFastBacilli(AFB)ondirectsputumsmear
microscopywithorwithoutradiographicabnormalitiesconsistentwithactiveTB;or
2. with one sputum specimen positive for AFB and with radiographic abnormalities
consistentwithactiveTBasdeterminedbyclinician;or
3. with one sputum specimen positive for AFB with sputum culture positive of
Mycobacteriumtuberculosis
96
FHSIS DIC 201201
AllformsofTBcaseswriteonthespaceprovidedthenumberofpersonswhoarecasepositive
classified as both Pulmonary and Extrapulmonary. (See Annex 2.8 ITRTuberculosis Prevention
andControlProgram)
NewSmear(+)casesinitiatedtreatment.NewsmearpositivecasesareTBpatientsthathavenot
takenantiTBdrugsbeforeoriftheyhavetakenantiTBdrugsforlessthan1month.Writeon
thespaceprovidedthenumberofnewsmearpositivecasesgiventreatmentandregisteredin
aDOTfacility.(SeeAnnex2.8ITRTuberculosisPreventionandControlProgram)
Newsmearpositivecasescuredwriteonthespaceprovidedthenumberofnewsmearpositivecases
whohavecompletedtreatmentandissmearnegativeinthelastmonthoftreatmentandonat
least one previous occasion in the continuation phase. (See Annex 2.8 ITR Tuberculosis
PreventionandControlProgram)

Smear positive retreatment cases initiated treatment write on the space provided the number of
smear positive retreatment cases given treatment and registered in a DOTS facility Re
treatmentcasesrefertoRelapse,ReturnafterDefault,TreatmentFailureandOthertypeofTB
cases(SeeAnnex2.8ITRTuberculosisPreventionandControlProgram)

Relapse
Treatmentfailure
Returnafterdefault
OthertypesofTB
Smearpositiveretreatmentcaseswhogotcuredwriteonthespaceprovidedthenumberofsputum
smear positive (+) re treatment patient who has completed treatment and is now sputum
smearnegative()inthelastmonthoftreatmentandonatleastonepreviousoccasioninthe
continuationphase.(SeeAnnex2.8ITRTuberculosisPreventionandControlProgram)
Relapse
Treatmentfailure
Returnafterdefault
2.15.7Schistosomiasis
Symptomatic Case write on the space provided the number of schistosomiasis cases. (See Annex
2.11SchistosomiasisPreventionandControlProgram)
PositiveCasewriteonthespaceprovidedthenumberofschistosomiasiscasesfoundpositive.(See
Annex2.11SchistosomiasisPreventionandControlProgram)
Case infected with low, medium and high intensity write on the space provided the number of
schistosomiasis cases with low, medium and high intensity. (See Annex 2.11 Schistosomiasis
PreventionandControlProgram)
Casestreatedwriteonthespaceprovidedthenumberofschistosomiasiscasestreated.Treatmentof
casesistheadministrationofPraziquantel,600mggivenjustonedayin23divideddosesat40
60mg/kg.(SeeAnnex2.11SchistosomiasisPreventionandControlProgram)
Casesreferredtohospitalfacilitieswriteonthespaceprovidedthenumberofschistosomiasiscases
referredtohospitalfacilities.(SeeAnnex2.11SchistosomiasisPreventionandControlProgram)
97
2.17 Monthly Form for Program Report (M1)
FHSIS version 2012
FHSIS REPORT for the MONTH________ YEAR: _____

Name of BRGY: __________________________________
Name of BHS: ___________________________________
Municipality/City of: _______________________________
Province: _______________________________________
Projected Population of the Year: ____________________
For submission to RHU
MATERNAL CARE No.
Deliveries
Pregnant women with 4 or more Prenatal visits
Pregnant women given 2 doses of Tetanus Toxoid
Pregnant women given TT2 plus
Preg.women given complete iron w/folic acid supplementation
Postpartum women with at least 2 postpartum visits
Postpartum women given complete iron supplementation
10-49 years old women given Iron supplementation
Postpartum women given Vitamin A supplementation
PP women initiated breastfeeding w/in 1 hr.after delivery
No. of pregnant women
No. of pregnant women tested for syphilis
No. of pregnant women positive for syphilis
No. of pregnant women given Penicillin
Acceptors New
Current
Dropout Acceptors
Current User New Other User
FAMILY PLANNING METHOD (Beg Mo.)
(Present
(End of
of the
Acceptors Acceptors
Month) present
(Previous Month)
Month)
(Present Month) Month
a. Female Sterilization/BTL
b. Male Sterilization/Vasectomy
c. Pills
d. IUD
e. Injectables (DMPA/CIC)
f. NFP-CM
g. NFP-BBT
h. NFP-STM
i. NFD-Standard Days Method
j. NFP-LAM
k. Condom
l. Implant
Total
102
Note: Have a separate report for new acceptors for the month/quarter for method SEE BACK PAGE
M-Form page 2
CHILD CARE Male Female Total CHILD CARE Male Female Total
Immunization given <1 yr Chidren 24-35 months old received Vitamin A
BCG Chidren 36-47 months old received Vitamin A
w/in 24 hrs Chidren 48-59 months old received Vitamin A

Hepa B1
> 24 hrs Infant 2-5 months old received Iron
1 Infant 6-11 months old received Iron
PENTA 2 Chidren 12-23 months old received Iron
3 Chidren 24-35 months old received Iron
1 Chidren 36-47 months old received Iron
OPV 2 Chidren 48-59 months old received Iron
3 Infant 6-11 months received MNP
MCV1 (AMV) Children 12-23 months received MNP

MCV
MCV2 (MMR) Sick Children 6-11 months seen
1 Sick Children 12-59 months seen
ROTA 2 Sick Children 6-11 months received Vitamin A
3 Sick Children 12-59 months received Vitamin A
1 Children 12-59 months old given de-worming tablet
PCV 2 Infant 2-6 mos w/Low Birth Weight seen
3 Infant 2-6 mos w/ LBW received full dose iron
Fully Immunized Child (0-11 mos) Anemic Children 6-11 months old seen
Completely Immunized Child (12-23 mos) Anemic Children 6-11 mos received full dose iron
Total Livebirths Anemic Children 12-59 months old seen
Child Protected at Birth (CPAB) Anemic Children 12-59 mos received full dose iron
Infant age 6 mos. seen Diarrhea cases 0-59 months old seen
Infant exclusively breastfed until 6th mo. Diarrhea cases 0-59 mos old received ORS
Infant given complimentary food from 6-8 months Diarrhea 0-59 mos received ORS/ORT w/ zinc
Infant referred for newborn screening Pneumonia cases 0-59 months old
Infant 6-11 months old received Vitamin A

Pneumonia cases 0-59 mos old completed
Chidren 12-23 months old received Treatment
Vitamin A
STI SURVEILLANCE Male Female Total

No. of pregnant women
No. of pregnant women tested for syphilis
No. of pregnant women positive for syphilis
No. of pregnant women given Penicillin
103
M-Form page 3
MALARIA Male Female Total SCHISTOSOMIASIS Male Female Total
Total Population No. of Symptomatic case
Population at risk No. of Cases Examined
Annual Parasite Incidence No. of Positive Cases
Confirmed Malaria Case Low intensity
< 5 yo Medium intensity
> = 5 yo High intensity
Pregnant No. of Cases treated
Confirmed malaria case No of Complicated Cases
By Species No. of Complicated Cases referred
P.falciparum
P.vivax
P.ovale FILARIASIS Male Female Total
No. Cases with hydrocele, lymphedema,
P.malariae
Elephantiasis, Chyluria
Confirmed malaria case Clinical Rate
By Method: No of Case examined
Slide No of Cases examined found Positive for MF
RDT Average MFD
Malaria Deaths Eligible population given MDA (94.6% of TP)
Population given LLIN Total population given MDA
TUBERCULOSIS Male Female Total LEPROSY Male Female Total
1. TB symptomatics who underwent DSSM Total Population
Total No. of Leprosy cases (undergoing
2. Smear positive discovered and identified treatment
3. New smear positive cases initiated tx and registered No. of Newly detected Leprosy Cases
4. New smear (+) cases cured < 15 yo
5. Smear(+) retreatment cases cured Grade 2 disability
6. Smear (+) retreatment cases initiated tx and registered No of Leprosy Cases cured
Relapse
Treatment failure
Other type of TB
7. No, of Smear (+) retreatment cured
Relapse
Treatment failure
8.Total No. of TB cases (all forms) initiated treatment
104
2.18 Morbidity Disease Report (A2)
. FHSIS v. 2012
FHSIS MONTHLY REPORT for: Year:

Name of BRGY and BHS:
Catchment Health Center:
MORBIDITY DISEASES REPORT

For submission to the PHO
ICD 10 Under 1 1 - 4 5 - 9 10 - 14 15 - 19 20 - 24 25 - 29 30 - 34 35 - 39 40 - 44 45- - 49 50 - 54 55 - 59 60 - 64 65 & above T OT AL
DISEASE
CODE M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F Total
Influenza J11
Acute Hemorrhagic Fever Syndrome
A91
(Dengue)
Pneumonia J18.9
Cholera A00
Diphtheria A36
Filarisis B74
Leprosy A30
Leptospirosis A27
Malaria B50-B54
Measles B05
Meningococcemia A39

Rabies A82
Schistosomiasis B65
Syphilis A50-A53
Gonorrhea A54.9
Genital Ulcer N48.5, N76.5, N76.6,
106
. FHSIS v.2008
FHSIS MONTHLY REPORT for: Year:

Name of BRGY and BHS:
Catchment Health Center:
For submission to RHU
Under 1 1 - 4 5 - 9 10 - 14 15 - 19 20 - 24 25 - 29 30 - 34 35 - 39 40 - 44 45- - 49 50 - 54 55 - 59 60 - 64 65 & above TOTAL

DISEASE
M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F
105
FHSIS DIC 201201
2.19THEQUARTERLYFORMFORPROGRAMREPORT(Q1):
TheQuarterlyFormistheofficialhealthreportofthemunicipality/cityforthequarter.Itcontainsthe
consolidated three month reports of all the BHSs and the RHU/MHC for health service delivery during the
quarter.ThePHNforwardsthisreporttotheProvincialFHSISCoordinatoratthePHOeverythirdweekofthe
first month of the succeeding quarter for provincial consolidation. The municipality/city prepared only one
quarterlyreport.IncasethereismorethanoneRHU/MHCinthemunicipality/city,theMHO/CHOwhositsas
thevicechairmanoftheLHBshallberesponsiblefordirectingtheconsolidationofallthequarterlydatafrom
different RHUs/MHCs and the preparation of one Quarterly Form for the municipality/city. Spaces are left
blankforthoseindicatorsthemunicipality/citywantstogeneratebasedontheirlocalneedsandinterests.
HeadingFilluptheheadingwiththedatabeingaskedfor:IdentifytheQuarterandYear.Placefullnameof
theMunicipality/CityandtheProvincetowhichtheLGUbelongs.
Projectedpopulationfortheyearwriteonthespaceprovidedthecityormunicipalitypopulation.
FillinguptheformTheQuarterlyFormisdesignedbyprogramwiththeindicatorslistedinthefirstcolumn,
followedbytheeligiblepopulation,numberofmaleandfemalecases,thetotalforbothsexes,the
percentageaccomplishment,theinterpretationoranalysisofdataandrecommendationsoractions
taken by your area. Denominators for some indicators are listed below for easy computation. All
indicators found in the Monthly Form should have the same definitions except for Dental Health
whichcanonlybefoundintheQuarterlyForm.
2.19.1MaternalCare PutthetotalsforthequarterperindicatorandplaceInterpretationand
Recommendations/Actionstaken.
2.19.2FamilyPlanning PutthetotalsforthequarterperindicatorandplaceInterpretationand
2.19.3ChildCare PutthetotalsforthequarterperindicatorandplaceInterpretationand
2.19.4DentalCare

Orally Fit Children 1271 months old write on the space provided the number of children whose ages
ranges from 12 to 71 months old and meet all of the following upon oral examination and/or
completion oftreatment:(1) cariesfree or decayed teethy filled (permanent fillings)(2) has healthy
gums (3) no oral debris and (4) no dentofacial anomaly that limits normal function.(See Annex 2.7
DentalHealthProgramform1)PlaceInterpretationandRecommendations/Actionstaken.
Children1271monthsoldprovidedwithBasicOralHealthCare(BOHC)writeonthespaceprovidedthe
numberofchildrenwhoseagesrangesfrom12to71monthsoldandwereprovidedwithBasicOral
HealthCareduringthequarter.BasicOralHealthCarereferstooneofmoreofthefollowingservices:
(1) Oral Examination (2) 80% Attendance to Supervised Tooth Brushing (3) Atraumatic Restorative
Treatment(ART)and(4)OralUrgentTreatment(OUT)whichincludesremovalofunsavableteethor
referral of complicates cases of treatment of postextraction complications or drainage of localized
oral abscess. (See Annex 2.7 Dental Health Program form 1) Place Interpretation and
AdolescentandYouth(1024yearsold)providedwithBasicOralHealthCare(BOHC)writeonthespace
providedthenumberofyouthandadolescentswhoseagesrangesfrom10to24yearsoldandwere
providedwithBasicOralHealthCareduringthequarter.BasicOralHealthCarereferstooneofmore
of the following services: (1) Oral Examination (2) Education and counseling on health effects of
tobacco/smoking, diet and oral hygiene. (See Annex 2.7 Dental Health Program form 1) Place
105
FHSIS DIC 201201
InterpretationandRecommendations/Actionstaken.
PregnantwomenprovidedwithBasicOralHealthCare(BOHC)writeonthespaceprovidedthenumberof
pregnantwomenwhowereprovidedwithBasicOralHealthCareduringthequarter.BasicOralHealth
Carereferstooneofmoreofthefollowingservices:(1)OralExamination(2)Scaling(3)Permanent
Fillingand(4)GumTreatment.(SeeAnnex2.7DentalHealthProgramform1)PlaceInterpretationand
OlderPersons60yearsoldandaboveprovidedwithBasicOralHealthCare(BOHC)writeonthespace
provided the number of older persons ages 60 years old and above who were provided with Basic
Oral Health Care during the quarter. Basic Oral Health Care refers to one of more of the following
services: (1) Oral Examination (2) Extraction and (3) Gum Treatment. (See Annex 2.7 Dental Health
Programform1)PlaceInterpretationandRecommendations/Actionstaken.
2.19.5Tuberculosis PutthetotalsforthequarterperindicatorandplaceInterpretationand
2.19.6Leprosy PutthetotalsforthequarterperindicatorandplaceInterpretationand
2.19.7Malaria PutthetotalsforthequarterperindicatorandplaceInterpretationand
2.19.8Schistosomiasis PutthetotalsforthequarterperindicatorandplaceInterpretationand
2.19.9Filariasis PutthetotalsforthequarterperindicatorandplaceInterpretationand
2.21THEQUARTERLYCONSOLIDATIONREPORTOFMORBIDITYDISEASES(Q2):
The Quarterly Report of Morbidity Diseases contains a list of all diseases by age and gender. It summarizes
quarterlyofdiseasesthatarereportedinthemunicipality/cityforwhichthePHNisresponsible,thenforwards
this report to the Provincial FHSIS Coordinator at the PHO every third week of the first month of the
succeedingquarterforprovincialconsolidation.
HeadingFilltheYearforwhichthereportisbeingprepared.Writethefullnameofthe
Municipality/CityandProvinceandthequarter.
Fillingupthereport
Writeinthespaceprovidedthediseasename,thequartertotalnumberofmales(M)andfemales(F)
for the corresponding age grouping reported for the particular disease. Data for the quarterly
consolidationcomesfromtheMonthlyReportoftheMidwifeanddatafoundintheRHU.
106
2.20.1 Maternal Care
FHSIS ver 2012
FHSIS REPORT for the QUARTER_________________ YEAR: ______________

logo Municipality/City Name: _______________________________________________
Province: ___________________Projected Population of the Year: ____________
- MATERNAL CARE -
Elig Recommendation/
Indicators No. % Interpretation
Pop. Actions Taken
Col. 1 Col.2 Col. 3 Col.4 Col. 5 Col. 6
Deliveries
Pregnant women with 4 or more prenatal visits
Pregnant women given 2 doses of Tetanus Toxoid
Pregnant Women given TT2plus

Pregnant women given complete iron with folic acid
supplementation
Post partum women with at least 2 post-partum visits
Post partum women given complete iron

supplementation
Proportion of Post partum women given Vitamin A
supplementation
Proportion Postpartum women initiated breastfeeding
within 1 hour after giving birth
10-49 years old women given Iron supplementation
Eligible Population: TP x 2.7%
109
2.20.2 Family Planning FHSIS v. 2012 - Q Form (page 2 of 8)
- FAMILY PLANNING-
Acceptors New
Current
Current User Acceptors CPR = (Col. Recommendations/ Actions
Indicators Dropout Users End Interpretation
(Beg. of Quarter) of the 5/TP x 12.325%) Taken
of Quarter
New Other Quarter
(end of Qtr) (end of Qtr)
Col. 1 Col.2 Col.3 Col.4 Col.5 Col.6 Col.7 Col.8 Col.9
a. Female Ster/BTL
b. Male Ster/Vasectomy
c. Pills
d. IUD
e. Injectables (DMPA/CIC)
f. NFP-CM
g. NFP-BBT
h. NFP-STM
i. NFP-SDM
j. NFP-LAM
k. Condom
l. Implants
110
2.20.3 Child Care FHSIS v. 2012 - Q Form (page 3 of 8)
- CHILD CARE -
Elig. Number Recommendation/
Indicators % Interpretation
Pop. Male Female Total Actions Taken
Col. 1 Col.2 Col. 3 Col. 4 Col. 5 Col. 6 Col. 7 Col. 8
Infants given BCG
w/in 24 hours
Infants given HepatitisB1
> 24 hours
1
Infants given PENTA 2
3
1
Proportion of Infants given OPV 2
3
MCV1 (AMV)
Proportion of Infants given MCV
MCV2 (MMR)
1
Proportion of Infants given ROTA 2
3
1
Proportion of Infants given PCV 2
3
Proportion of Fully Immunized Child (0-11 mos)
Proportion of Completely Immunized Child (12-23 mos)
Total Livebirths
Proportion of Child Protected at Birth (CPAB)
Proportion of Infants age 6 mos. seen
Proportion of Infants exclusively breastfed until 6th month old
Infants given complimentary food from 6-8 months
Proportion of Infants referred for newborn screening
Eligible Population: TP x 2.7% Total Livebirths No. Infant seen at 6th month
111
FHSIS v. 2012 - Q Form (page 4 of 8)
- CHILD CARE - 112

Infant 6-11 months old received Vitamin A
Children 12-23 months old received Vitamin A*
Infant 2-5 months old received Iron
Infant 6-11 months old received Iron
Children 12-23 months old received Iron *
Infant 6-11 months old received MNP
Children 12-23 months old received MNP
Sick Children 6-11 mos. seen
Sick Children 12-59 mos. seen
Sick Children 6-11 mos. received Vit. A
Sick Children 12-59 mos. received Vit.A
Children 12-59 mos. old given de-worming tablet
Infant 2-6 mos.w/ low birthweight seen
Infant 2-6 mos.w/ low birthweight received full dose iron
Anemic Children 6-11 months old seen
Anemic Child. 6-11 months old seen received iron
Anemic Children 12-59 months old seen
Anemic Child. 12-59 months old seen received iron
Diarrhea cases 0-59 months old
Diarrhea cases 0-59 mos old received ORS
Diarrhea 0-59 mos old received ORS/ORT w/ zinc
Pneumonia cases 0-59 mos. old seen
Pneumonia cases 0-59 mos. old completed Tx
Eligible Pop: TP x 1.35% * TP x 11% TP x 2.7% Sick Child 6-11 mos. seen Sick Child 12-59 mos. seen
Infant 2-6 mos.w/LBW seen Anemic Child 12-59 mos. old seen No.Diarrhea cases 0-59 mos old seen No.Pneumonia cases 0-59 mos seen
112
2.20.4 Dental Care FHSIS v. 2012 - Q Form (page 5 of 8)
- DENTAL CARE -
Orally Fit Children 12-71 months
old
Children 12-71 months old
provided with BOHC
Adolescent & Youth(10-24 years)
given BOHC
Pregnant women provided
with BOHC
Older Person 60 yrs old & above
provided with BOHC
Eligible Population: TP x 13.5% TP x 30% TP x 2.7% TP x 6.9%
113
2.20.5 Disease Control
FHSIS v. 2012- Q Form (page 6 of 8 )
- DISEASE CONTROL -
Number Recommendation/
TUBERCULOSIS Interpretation
Male Female Total Actions Taken
Col. 1 Col. 2 Col. 3 Col. 4 Col. 5 Col. 6
1. TB symptomatics who underwent DSSM
2. Smear positive discovered and identified
3. New smear positive cases initiated tx and registered
4. New smear (+) cases cured
5. Smear(+) retreatment cases cured

6. Smear (+) retreatment cases initiated tx and registered
Relapse
Treatment failure
Other type of TB
7. No, of Smear (+) retreatment cured
Relapse
Treatment failure
8.. Total No. of TB cases (all forms) initiated treatment

LEPROSY Male Female Total
Rate Interpretation
Actions Taken
Col. 1 Col. 2 Col. 3 Col. 4 Col. 5 Col. 6 Col. 7
1. Total Population
2. Total No. of Leprosy cases (undergoing Treatment)
Leprosy cases
< 15 yo
Grade 2 disability
4. No of Leprosy Cases cured
Denominator TP x 0.00275 (estimated TB All Forms)
114
FHSIS v. 2012- Q Form (page 7 of 8)
- DISEASE CONTROL -
MALARIA Number Recommendation/
Rate Interpretation
(endemic areas) Male Female Total Actions Taken
Total Population
Population at risk
Morbidity Annual Parasite
Rate Incidence
Annual Parasite Incidence
Confirmed Malaria Case

By age group
< 5 yo
> =5 yo
By pregnancy
Pregnant
By species
P.falciparum
P. vivax
P.ovale
P.malariae
By Method
Slide
RDT
Total no. of LLIN given
Mortality Case Fatality
Rate Ratio
Total no. of Malaria Deaths
Denominator: Morbidity Rate=TP; Annual Parasite Incidence=Endemic Pop >5 & <5 yo Population
Total Confirmed Malaria Case Population at risk Mortality rate=TP; Case Fatality Ratio=Total Malaria Cases
115
FHSIS v. 2012 - Q Form (page 8 of 8)
- DISEASE CONTROL -
SCHISTOSOMIASIS Number Recommendation/
Rate Interpretation
Symptomatic cases
Case examined
Positive Cases
Low intensity
Medium intensity
High intensity
Cases treated
Complicated Cases *
Complicated Cases referred
FILARIASIS Number Recommendation/
Rate Interpretation
1.No. Cases with hydrocele,

lymphedema, Elephantiasis,
Chyluria
2. Clinical Rate
4. No of Cases examined found
Positive for MF
5. Average MFD
6. Eligible population given MDA
(94.6% of TP)
7. Total population given MDA
Denominator for Schistosomiasis: Case examined Positive Schistosomiasis cases *Complicated cases
116
2.21.1 Form 1 Notifiable Diseases FHSIS v. 2012 - Qmorbid (page 2 of 2)
. FHSIS v.2012
FHSIS QUARTERLY REPORT for: Year:

Municipality/City of:
ProvInce
OF ICD Code Under 1 1-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70 & over TOTAL
Influenza J11
Acute Hemorrhagic Fever Syndrome (Dengue) A91
Pneumonia J18.9
Cholera A00
Diphtheria A36
Filarisis B74
Leprosy A30
Leptospirosis A27
Malaria B50-B54
Measles B05
Meningococcemia A39
Rabies A82
Schistosomiasis B65
Syphilis A50-A53
Gonorrhea A54.9
Genital Ulcer N48.5, N76.5, N76.6
118
2.21.2 Form 2 Other Diseases FHSIS v. 2012 - Qmorbid (page 1 of 2)
.
FHSIS QUARTERLY REPORT for: Year:
ProvInce
DISEASE
CODE M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F
117
FHSIS DIC 201201
2.22THEANNUALFORMS:
2.22.1AnnualBHSReport(ABHS)

TheAnnualBHSReportFormcontainsbasicinformationabouttheBHSwhicharesubmittedonlyonceyear.It
consistsofdatacategorizedunderdemographic,environmentalandnatality.ThemidwifeintheBHSfillsup
theformandsubmitstotheRHU/MHCforconsolidation.

Heading
Fill in the required information for the Year, complete name of the BHS, municipality/city and the
province.
Fillinguptheform.
ForDemographicProfile,writethepopulation,numberofbarangaysandhouseholds.Theindicators
arethesamewiththosefoundintheAnnualForm1andsamedefinitionsmustbefollowed.
2.22.2AnnualForm1VitalStatisticsReport(A1RHU)

TheAnnualFormcontainsbasicinformationaboutthemunicipalityorcitywhichisbeingsubmittedonlyonce
ayear.Itconsistsofdatacategorizedunderdemographic,environmental,natalityandmortality.Thenursein
theRHU/MHCfillsuptheformandsubmitstothePHOforcomputerprocessing.
Heading
FillintherequiredinformationfortheYear,completenameoftheRHUandprovince.
Fillinguptheform
The Annual Form consists of the program indicators listed in the first column, followed by the
number,thepercentageaccomplishmentorratio/rate,theinterpretationoranalysisofdataandthe
recommendations or action taken by your area. To facilitate computation of rates/ratios,
denominatorsforsomeindicatorsarelistedbelow.
2.22.2.1DemographicInformation
No. of Barangays Write on the space provided the actual number of barangays within the
municipality/city.
No.ofBHSsWriteonthespaceprovidedtheactualnumberofbarangayhealthstations.ABHS
canbeconsideredareportingunitifthefollowingconditionsaresatisfied:

a. Itrenders/delivershealthservicestoadefinedcatchmentareawhichmaybecomposed
ofoneormorebarangays.
b. Amidwiferendersregularservicetothearea.Incasewherethemidwifeoftheareais
in prolonged leave of absence or resigned but a replacement is expected, the BHS
remainsareportingunit.Thereportsareexpectedtobesubmittedbythenurse(2)or
midwife(s)whotookovertheservicingofthearea.
c. Healthservicesmaybeprovidedfromanyphysicalstructuredesignatedforthe
purposei.e.aBHSbuilding,abarangayhalloraplaceofresidence.
d. ThecatchmentareaservedisnotaserviceareaofanyRHU.Forinstance,Poblacionin
mostcasesisthecatchmentareaservedbytheRHU.Thus,thePoblacionBHScannotbe
consideredareportingunit.ThereportsofthisBHSshouldbepreparedandsubmitted
bytheRHU.
e. ItshouldnotincludesatelliteBHSwhicharevisitedbythemidwifebutpartofthe
catchmentofthemotherBHS.

117
FHSIS DIC 201201
No.ofHealthWorkersinLGUThisincludesnationallypaidpublichealthworkersandthosehired
bythelocalgovernment.Writeonthespaceprovidedthetotalnumberofdoctors,dentists,
nurses, midwives, nutritionists, medical technologists, engineers, sanitary inspectors and
activeBHWs.

NOTE:Hospitalpersonnelarenotincludedinthisindicator.
2.22.2.2ENVIRONMENTAL
No.ofHouseholds(HH)Writeonthespaceprovidedtheactualnumberofhouseholdsinthe
municipality.Thedatashouldbebasedonactualhouseholdsurveywithinthelocality.

Households with access to improved or safe water supply Write on the space provided the
number of households covered by or have access to the following types of drinking water
sources that conforms to the Philippine National Standards for Drinking Water (PNSDW)
(i.e.,freefrombacterial,chemical,physicalandothercontaminants):
LevelI(PointSource)Aprotectedwell(shallowanddeepwell)improveddugwell,
developedspring,rainwatercisternwithanoutletbutwithoutdistributionsystem.

LevelII(CommunalFaucetSystemorStandpost)Referstoasystemcomposedofasource,
areservoir,apipeddistributionnetwork,andacommunalfaucetlocatednotmorethan25
meters from the farthest house. It is generally suitable for rural and urban areas where
houses are clustered densely enough to justify a simple piped water system. Note: For
reportingpurposesLevelIIsystemmayalsoincludeacommunalfaucetconnectedtoLevelIII
wheregroupofhouseholdsgettheirwatersupply.

LevelIII(WaterworksSystem)Asystemwithasource,transmissionpipes,areservoir,
and a piped distribution network for household taps. It is generally suited for densely
populatedareas.ExamplesoftheseareMWSSandwaterdistrictswithindividualhousehold
connections. Note: For reporting purposes of Level III system may also include a Level I
system with piped distribution for household tap serving individual or group of housing
dwellingssuchasapartmentsorcondominiums.
HouseholdswithsanitarytoiletfacilitiesWriteonthespaceprovidedthetotalnumberof
households with sanitary toilets. This refers to households with flush toilets connected to
septic tank and/or sewerage system or any other approved treatment system, sanitary pit
latrineorventilatedimprovedpitlatrine.

HouseholdswithsatisfactorydisposalofsolidwasteWriteonthespaceprovidedthetotal
number of households with garbage disposal through composting, burying, city/municipal
systemstorage,collectionanddisposal.
HouseholdswithcompletebasicsanitationfacilitiesWriteonthespaceprovidedthetotal
numberofhouseholdswhichsatisfythepresenceofthefollowingbasicsanitationelements,
namely: access to safe water, availability of a sanitary toilet and satisfactory system of
garbagedisposal.

FoodEstablishmentsWriteonthespaceprovidedthetotalnumberoffoodestablishments
whichincludesrestaurants,sarisaristores,canteens,coffeeshops,carinderia,refreshment
parlors, bakeries, water refilling stations, food manufacturing, bottling, dairy and canning
establishments.
FoodEstablishmentswithSanitaryPermitWriteonthespaceprovidedthetotalnumberoffood
establishmentswithsanitarypermit.
118
FHSIS DIC 201201

FoodHandlersWriteonthespaceprovidedthetotalnumberoffoodhandlersemployedinfood
establishments
FoodHandlerswithHealthCertificatesWriteonthespaceprovidedthetotalnumberoffood
handlerswithhealthcertificates.

2.22.2.3NATALITY
No.ofPregnanciesWriteonthespaceprovidedthetotalnumberofpregnancies.
Pregnancybyoutcome

Livebirths writeonthespaceprovidedthetotalnumberoflivebirths
FetalDeaths writeonthespaceprovidedthetotalnumberoffetaldeath

Abortion writeonthespaceprovidedthetotalnumberofabortion
No.ofdeliveriesbytype

NormalSpontaneousDelivery(NSD)writeonthespaceprovidedthetotalnumberofNSD
OtherswriteonthespaceprovidedthetotalnumberdeliveriesotherthanNSD

Weightatbirth

2,500gramsandgreater Writeonthespaceprovidedthetotalnumberoflivebirthswith
weightsequaltoorgreaterthan2,500grams.

Lessthan2,500grams Writeonthespaceprovidedthetotalnumberoflivebirthswith
weightslessthan2,500grams.

Notknown Writeonthespaceprovidedthetotalnumberoflivebirths
whoseweightsatbirtharenotknown.

DeliveriesAttendedby:
Doctors Writeonthespaceprovidedthenumberofdeliveriesbydoctors.

Nurses Writeonthespaceprovidedthenumberofdeliveriesattendedbynurses.

MidwivesWriteonthespaceprovidedthenumberofdeliveriesattendedbymidwives.

TrainedHilot/TBAWriteonthespaceprovidedthenumberofbirthsattendedbytrained
hilotorhealthworkernotmentionedabove.

OthersWriteonthespaceprovidedthenumberofbirthsattendedbythoseotherthan
theabovementioned.

119
FHSIS DIC 201201
No.oflivebirths
Column2(Male)writeonthespaceprovidedthetotalnumberofmaleswerebornalivein
theHealthCenterfromTCLofprenatalandLCR.

Column 3(Female) write on the space provided the total number of females who were
bornaliveintheHealthCenterfromTCLofprenatalandLCR.

Column4(Total)writeonthespaceprovidedthetotalnumberof
femalesandmaleswhowerebornaliveintheHealthCenterfromTCLofprenatalandLCR.

Column5(Percent)writeonthespaceprovidedthepercentofthetotalnumberoffemales
andmaleswhowerebornaliveintheHealthCenterfromTCLofprenatalandLCR.
DeliveriesbyPlace:
Health Facility Hospital, RHU or Lyingin (including BEMONC, CEMONC) write on the
spaceprovidedthetotalnumberoflivebirthsthatweredeliveredingovernmentorprivate
hospitals,RHUorLyingin(includingBEMONC,CEMONC).

NoninstitutionalDelivery(NID)writeonthespaceprovidedthetotalnumberoflivebirths
thatweredeliveredinhomeorotherthanhealthfacility.

2.22.2.4MORTALITY
Deathsbysex:
Male writeonthespaceprovidedthetotalnumberofmaledeaths
Female writeonthespaceprovidedthetotalnumberoffemaledeaths

MaternalMortalitywriteonthespaceprovidedthetotalnumberofpregnantwomenwhodied
duetocausesrelatedtopregnancy,childbirthandpuerperium.

InfantMortalitywriteonthespaceprovidedthetotalnumberofinfantdeaths.

UnderFiveMortalitywriteonthespaceprovidedthetotalnumberofdeathsamongchildren
underfiveyearsofage.

Fetal Deaths write on the space provided the total number of fetus who reaches the age of
viability(20weeks+),andaweightofmorethan500gramsdelivereddeadordiedinsidethe
womb.

PerinatalDeathswriteonthespaceprovidedthetotalnumberoffetuswhodiedfrom22ndweek
of gestation (the time when birth weight is normally 500mg) and ends 7 completed days
afterbirth.
NeonatalMortalitywriteonthespaceprovidedthetotalnumberofdeathsbetweenbirthsupto
28daysofage.
DeathsduetoNeonatalTetanuswriteonthespaceprovidedthetotalnumberofdeaths3to28
daysofageduetotetanusneonatorum.

120
FHSIS DIC 201201
AnnualForm2MorbidityDiseaseReport
This report is prepared by the PHN as the annual consolidation of the monthly and quarterly
morbiditydiseasereportsfromtheBHSsandtheRHUs.TheSourceofthisreportistheSummaryTable.The
reportconsistsofallreportedcausesofmorbiditydiseaseswithageandsexbreakdown,andsubmittedtothe
PHO.
AnnualForm3MortalityReport
Thisreportistheannualconsolidationofalldeathsoccurredinyourarea.TheSourceofthisreportis
theSummaryTable.ThePHNwhopreparesthisreportbreaksdownthenumberreportedineachdiseaseby
ageandgender.
121
2.22.3.2 Demographic Profile (A1-RHU)
FHSIS version 2012
FHSIS ANNUAL REPORT FOR YEAR: ______________________________________

Municipality/City Name: ___________________________________________________
No. of Health Centers _____________________
Province: _____________________Projected Population of the Year: ___________
- DEMOGRAPHIC PROFILE -
Number Ratio to Recommendation/
Indicators Interpretation
Male Female Total Pop. Actions Taken
Barangays
Barangay Health Stations
Health Centers
Households
Physicians/Doctors
Dentist
Nurses
Midwives
Medical Technologists
Sanitary Engineers
Sanitary Inspectors
Nutritionist
Active Barangay Health Workers
124
2.22.3.3 Environmental FHSIS v. 2012 - A Form (page 2 of 5 )
- ENVIRONMENTAL -
Indicators No. % Interpretation Recommendation/
Actions Taken
Col. 1 Col 2 Col. 3 Col. 4 Col. 5
Total number of Households (HH)

HH w/ access to improved
water supply
- Level I
- Level II
- Level III
HH w/ sanitary toilet facilities
HH w/satisfactory disposal of solid waste
HH w/complete basic sanitation facilities
Food Establishment
Food Establishment w/Sanitary Permit
Food Handlers
Food Handlers w/Health Certificate

Denominator: No. Households No.Food Establishments No.Food Handlers
127
2.22.3.4 Natality - Livebirths FHSIS v. 2012- A Form (page 3 of 5)
NATALITY - LIVEBIRTHS
Col. 1 Col 2 Col 3 Col 4 Col. 5 Col. 6 Col. 7
No. of Pregnancies
Pregnacies by outcome
Livebirths (LB)
Fetal Death
Abortion
No. of Deliveries
NSD
Others
LB w/weights 2500 grams & greater
LB w/weights less than 2500 grams
LB - Not known weight
LB delivered by doctors
LB delivered by nurses
LB delivered by midwives
LB delivered by hilot/TBA
LB delivered by others
Denominator: Livebirths
128
2.22.3.5 Natality - Deliveries FHSIS v. 2012- A Form (page 4 of 5)
- NATALITY - DELIVERIES -
Indicators No. % Interpretation Recommendation/
Actions Taken
Col. 1 Col 2 Col. 3 Col. 4 Col. 5
Total No. of Pregnancies

Outcome of Pregnancy
Live Births
Fetal death
Abortion
Normal Deliveries
Deliveries at Home
Deliveries at Health Facility
Deliveries - Other Place
Other Deliveries
Deliveries at Home
Deliveries at Health Facility
Deliveries-Other Place
Denominator: Livebirths Pregnancies Normal Deliveries Other Type of Deliveries
126
2.22.3.6 Mortality FHSIS v. 2012 - A Form (page 5 of 5)
- MORTALITY -
Indicators Rate Interpretation
Col. 1 Col 2 Col 3 Col 4 Col. 5 Col. 6 Col. 7
Deaths
Maternal Deaths
Perinatal Deaths
Fetal Deaths
Neonatal Deaths
Infant Deaths
Deaths among child. Under 5 yrs old
Deaths due to Neonatal Tetanus
Denominator: Population Livebirths
125
. FHSIS v.2008
FHSIS ANNUAL REPORT for YEAR:

ProvInce
DISEASE
CODE M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F
129
2.22.3.8 Mortality Report (A3-RHU)
. FHSIS v.2012
FHSIS ANNUAL REPORT for YEAR:

ProvInce
MORTALITY REPORT
Under 1 1 - 4 5 - 9 10 - 14 15 - 19 20 - 24 25 - 29 30 - 34 35 - 39 40 - 44 45- - 49 50 - 54 55 - 59 60 - 64 65 & above T OT AL

DISEASE
M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F
130
Chapter Three
___________________
FHSIS VER. 2012

METADATA

FHSIS INDICATOR METADATA
TableofContents
Program/Topics Page
DemographicInformation .2
Natality .6
Mortality .9
EnvironmentalHealth .11
MaternalCare .14
FamilyPlanning .19
ChildCare .22
DentalHealth .31
Filariasis .33
Leprosy .35
Malaria .39
Schistosomiasis .42
Tuberculosis .44
MorbidityRates .47
FHSIS v. 2012
Indicator Metadata 3.1 DEMOGRAPHIC INFORMATION
_____________________________________________________________________________________________________________________________________________________________
Source of Frequencyof
Indicator Definition Formula Target UseandLimitation
Data Reporting
1.Population Thetotalnumberofinhabitantsconstitutingaparticular No.ofPopulation NSO Annual Instatisticstheentire
race,class,orgroupinaspecifiedarea. aggregationofitemsfrom
Disaggregation: Projected whichsamplescanbedrawn;
Region Population "itisanestimateofthemean
Province ofthepopulation"
Cities
2.No.ofMain MainHealthCenterreferstoanexpandedruralhealth
HealthCenters unit,usuallylocatedinastrategicareawherethereareno
hospitals.Ithasoneortwolyinginbedsandmayhavea
largerpersonnelcomplimentthanaregularRHU
3.No.ofBarangays Thetotalnumberofbarangayswithinthe No.of Barangays RHU Annual
municipality/city.
FHSIS
Disaggregation: DefinitionofTerms:
Region Abarangay(Tagalog:baranggay),alsoknownbyits
Province formername,thebarrio,isthesmallestlocalgovernment
Cities unitinthePhilippinesandisthenativeFilipinotermfora
village,districtorward.Municipalitiesandcitiesare
composedofbarangays.

4.No.ofBarangay Thetotalnumberofbarangayhealthstationswithinthe No.ofBHS RHUs Annual
HealthStations municipality/city. Reports

DefinitionofTerms:
BarangayHealthStationsreferstothefirstfacilityinthe
PublicHealthSystems.Itismannedbyacadreof
volunteerBHWsunderthesupervisionoftheRHM.The
MHOnormallyconductsdiagnosticconsultationsand
givesprescriptionsandreferralsonaregularbasisinthe
BHS.TheBHWsaretrainedinpreventivehealthcarewith
astrongemphasisonmaternalandchildcare,family
planningandreproductivehealth,nutritionand
sanitation,aswellas,preventionandcareofcommon
Data Reporting
diseases.
5.No.of Thetotalnumberofhouseholdsinthemunicipality/city No.ofHouseholds Houseto Annual
Households house
DefinitionofTerms: Survey
Disaggregation: Ahousehold(NSOdefinition)isasocialunitconsistingofa Note:Intheabsenceof
Region personlivingaloneoragroupofpersonswho: actualHHsurvey,usethe
Province 1)sleepinthesamehousingunit;and suggestedformulabelow
Cities 2)haveacommonarrangementforthepreparationand
consumptionoffood TotalPopulationdividedby6

6.RatioofPublic Thisincludesnationallypaidhealthworkersandthose Numerator:TotalPopulation Annual
HealthPersonnel hiredbythelocalgovernment.HealthManpowerincludes ofagivenarea
Doctors,Dentists,Nurses,Midwives,Medical
Technologists,SanitaryEngineers,SanitaryInspectorsand Denominator:TotalNo.of
ActiveBHWs. HealthManpower

DefinitionofTerms:

Physician/Doctorsallgraduatesofanyfacultyorschool Physician
ofmedicine,actuallyworkinginthecountryinany 1:20,000
medicalfield(practice,teaching,administration,research,
laboratory,etc.)

MunicipalHealthOfficerHe/Sheheadsthedecentralized
healthservicesatthemunicipallevelandservesas
administratoroftheruralhealthunit,theprimaryhealth
facilityinthearea.Asacommunityphysician,he/she
conductsepidemiologicalstudies/investigation,
formulateshealtheducationcampaignsondisease
prevention,andpreparesandimplementscontrol
measuresorrehabilitationplans.He/Shealsoserveas
themedicolegalofficer.Ashealthadministrator,his/her
functionsincludethepreparationofthemunicipalhealth
planandbudget;monitoringtheimplementationofbasic
healthservices,andmanagementoftheRHUstaff.

Dentistsareprofessionalpeoplequalifiedtoperform Dentist
Data Reporting
proceduresintheOralCavityinordertoprovide 1:50,000
preventive,curativeandrehabilitationservices.

Nursesallpersonswhohavecompletedaprogramof Nurse
basicnursingeducationandarequalifiedandregistered 1:20,000
orauthorizedtoprovideresponsibleandcompetent
serviceforthepromotionofhealth,preventionofillness,
careofthesick,andrehabilitation,andareactually
workinginthecountry.ThePublicHealthNurse(PHN)
supervisesandguidesallruralhealthmidwives(RHMs)in
themunicipality.He/Shehandlethehealthrecordsofthe
communityincludingdataonmorbidityandmortality
cases,programaccomplishments,etc.ThePHNalso
preparesmonthlyandquarterlyreportstotheMHO.

Midwivespersonswhohavecompletedaprogramof Midwife
midwiferyeducation,andhaveacquiredtherequisite 1:5,000
qualificationstoberegisteredand/orlegallylicensedto
practicemidwifery,andareactuallyworkinginthe
country.TheRuralHealthMidwife(RHM)managesthe
BHSandsupervisesandtrainstheBHWinthecommunity.
He/Sheprovidesmidwiferyservicesandexecuteheath
caretowomenofreproductiveageincludingfamily
planningcounselingandservices,He/Sheconducts
patientassessmentanddiagnosisforreferral/further
management;performshealthIECactivities,organizesthe
community,andfacilitatesBarangayhealthplanningand
othercommunityhealthservices.

MedicalTechnologistisadulylicensedhealthcare
professionalwhoworksonclinicallaboratoriesand
performsdiagnosticanalytictestsonhumanbodyfluids
suchasflood,urine,sputum,stool,cerebrospinalfluid
(CSF),peritonealfluid,pericardialfluid,andsynovialfluid,
aswellasotherspecimens.MedicalTechnologistsworkin
clinicallaboratoriesathospitals,doctorsoffice,reference
labs,andwithinthebiotechnologyindustry.

Data Reporting
SanitaryEngineersapersondulyregisteredwiththe RSI
BoardofExaminersforSanitaryEngineers(RA1364)and 1:20,000
whoheadsthesanitationdivisionorsectionorunitofthe
province/city/municipalhealthofficeoremployedwith
theDepartmentofHealthoritsregionalfieldhealthunits.

SanitaryInspectorsagovernmentofficialorpersonnel
employedbynational,provincial,cityormunicipal
governmentwhoenforcessanitaryrules,lawsand
regulationsandimplementsenvironmentalsanitation
activitiesunderthesupervisionoftheprovince/city/
municipalhealthofficer/sanitaryengineers.Rural
Sanitaryinspectors(RSI),functionsaredirectedtowards
ensuringahealthymunicipality.Thisentailsadvocacy,
monitoring,andregulatoryactivitiessuchas,inspectionof
watersupplyandunhygienichouseholdconditions.

Nutritionist/Dieticianisahealthspecialistthatdevotes Nutritionist
professionalactivitytofoodandnutritionalscience, 1:20,000
preventivenutrition,diseasesrelatedtonutrient
deficiencies,andtheuseofnutrientmanipulationto
enhancetheclinicalresponsetohumandiseases.Theycan
alsoadvisepeopleondietarymattersrelatingtohealth,
wellbeingandoptimalnutrition.

BarangayHealthWorker(BHW)anindigenousmember BHW
ofthecommunitythatactsasalinkofthehealthsystem 1:20HHs/
inthecommunity. 1:5,000
3.2 N A T A L I T Y
_____________________________________________________________________________________________________________________________________________________________
Sourceof Frequencyof
Data Reporting
1.CrudeBirthRate Theratioofthetotalnumberoflivebirthsinagiven Numerator:Totalnumberof LCR and Annual
populationduringayeartothemidyearpopulation Livebirths TCL
Disaggregation: duringagivenperiodexpressedper1,000population. (ensure
Livebirthsby Sometimesitisreferredtosimplyasthebirthrateand Denominator:Total mechanism
Sex alsolivebirthrate Population forno
double
DefintionofTerms: reporting)
Livebirthisthecompleteexpulsionorextractionfromits
motherofaproductofconception,irrespectiveofthe
durationofthepregnancy,which,aftersuchseparation,
breathesorshowsanyotherevidenceoflife,suchas
beatingoftheheart,pulsationoftheumbilicalcord,or
definitemovementofvoluntarymuscles,whetherornot
theumbilicalcordhasbeencutortheplacentais
attached;eachproductofsuchabirthisconsideredlive
born.
2.Proportionof Thisreferstobabiesbornalivewhoweigh2500gramsand Numerator:No.oflivebirths LCRand Annual TherateofLBWisarough
Livebirths greater,lessthan2500gramsandunknownweight. byweight TCL summarymeasureofmany
2500grams&greater (ensure factors,includingmaternal,
Disaggregation: DefinitionofTerms: lessthan2500grams mechanism nutrition,lifestyle(e.g.alcohol,
Livebirthsby notknown forno tobaccoanddruguse)and
weight Birthweightisthefirstweightoftheinfantobtainedafter double otherexposuresinpregnancy
birth.Forlivebirths,birthweightshouldpreferablybe Denominator:TotalNo.of reporting) (e.g.infectiousdiseasesand
measuredwithinthefirsthouroflifebeforesignificant Livebirths attitude).LBWisstrongly
postnatalweightlosshasoccurred. associatedwitharangeof
adversehealthoutcomes,such
2500gramsandgreaterlivebirthswithweightsequalto asperinatalmortalityand
orgreaterthan2500grams. morbidity,disabilityand
diseaseinlaterlife,butisnot
Lessthan2500gramslivebirthswithweightslessthan necessarilypartofthecause.
2500grams LBWisastrongpredictorofan
individualbabyssurvival.The
Notknownlivebirthswhoseweightsatbirtharenot lowerthebirthweightthe
known. highertheriskofdeath.
Data Reporting
3.Proportionof Thisreferstobirthsattendedbyskilledhealthpersonnel. Numerator:TotalNo.of 90%(NOH LCRand Annual Theindicatorhelpsprogram
birthsattended livebirthsattendedbyskilled 2016) TCL managementatdistrict,
byskilledhealth Definitionofterms: healthpersonnel (ensure nationalandinternational
personnel Skilledhealthpersonnel(sometimesreferredtoasskilled mechanism levelsbyindicatingwhether
attendant)isdefinedasanaccreditedhealthprofessional Denominator:TotalNo.of forno safemotherhoodprogramare
Disaggregation: suchasmidwife,doctorornursewhohasbeeneducated livebirths double ontargetintheavailabilityand
Livebirthsby andtrainedtoproficiencyintheskillsneededtomanage reporting) utilizationofprofessional
BirthAttendant normal(uncomplicated)pregnancies,childbirthandthe assistanceatdelivery.In
(doctor,nurse, immediatepostnatalperiod,andintheidentification, addition,theproportionof
midwife) managementandreferralofcomplicationsinwomenand birthsattendedbyskilled
newborns.Thisdefinitionexcludestraditionalbirth personnelisameasureofthe
attendantswhethertrainedornot,fromthecategoryof healthsystemsfunctioning
skilledhealthworkers. andpotentialtoprovide
adequatecoveragefor
MDGindicatorofProportion(%)ofbirthsattendedby deliveries.Ontheotherhand,
skilledhealthpersonnel:(G5.T6.I17):Percentageofbirths thisindicatordoesnottake
attendedbyskilledhealthpersonneltototalnumberof accountofthetypeandquality
livebirthsinagivenyear.Skilledhealthpersonnelrefer ofcare.
exclusivelytothosehealthpersonnel(forexample,
doctors,nurses,midwives)whohavebeentrainedto
proficiencyintheskillsnecessarytomanagenormal
deliveriesanddiagnoseorreferobstetriccomplications.
Traditionalbirthattendantstrainedoruntrainedarenot
includedinthiscategory.(WHO)

4.Proportionof Thisreferstodeliveriesbyplace. Numerator: 90%of LCRand Annual Proportionofbirthsdelivered
deliveriesbyplace No.ofDeliveriesat deliveries TCL inafacility.Itisameasureof
Healthfacility:hospitals,RHUs,lyingins(including home/healthfacility/ ina (ensure thehealthsystems
HealthFacilityor BEMONC,CEMONC) others health mechanism functionalityandpotentialto
Noninstitutional facility forno provideadequatecoveragefor
Delivery Noninstitutionaldeliveryincludes:homeandanydelivery No.ofOtherTypeof (NOH double deliveries.
otherthanhealthfacility deliveriesathome/ 2016) reporting)
healthfacility/others

Denominator:TotalNo.of
Deliveries

Data Reporting
5.Proportionof Thisreferstodeliveriesbytype. Numerator: LCRand Annual Whilethisisagoodmeasureof
deliveriesbytype No.ofDeliveriesat TCL riskfactoronpregnancyand
Definitionofterms: home/healthfacility/ (ensure childbirth,itdoesnot
Disaggregation: others mechanism adequatelymeasureorpredict
Type DeliveriesbyType: forno theoutcomeofthepregnancy
No.ofOtherTypeof double orchildbirthperse.Thenew
Normalreferstodeliveriesbynormalspontaneous deliveriesathome/ reporting) paradigmshiftisallpregnancy
delivery(NSD) healthfacility/others isatriskforcomplications.
OthersreferstodeliveriesdeliveredotherthanNSD
Deliveries
6.Proportionof Thisreferstopregnancybyoutcome. LCRand
pregnancyby TCL
outcome Livebirthisthecompleteexpulsionorextractionfromits (ensure
motherofaproductofconception,irrespectiveofthe mechanism
durationofthepregnancy,which,aftersuchseparation, forno
breathesorshowsanyotherevidenceoflife,suchas double
beatingoftheheart,pulsationoftheumbilicalcord,or reporting)
definitemovementofvoluntarymuscles,whetherornot
theumbilicalcordhasbeencutortheplacentais
attached;eachproductofsuchabirthisconsideredlive
born

FetalDeathdeathofthefetuspriortothecomplete
expulsionfromthemother;thedeathisindicatedbythe
factthatafterseparation,thefetusdoesnotbreathor
showanyevidenceoflifesuchasbeatingoftheheart,
pulsationoftheumbilicalcordordefinitemovementof
voluntarymuscles.(20weeksandabove)

Abortionistheterminationofapregnancybeforethe
fetushasattainedviability,i.e.becomecapableof
independentextrauterinelife

3.3 M O R T A L I T Y
_____________________________________________________________________________________________________________________________________________________________
Data Reporting
1.MortalityRate Anestimateoftheproportionofapopulationthatdies Numerator:No.ofpersons LCRand Annual
duringaspecifiedperiod. dyingduringtheperiod TCL,RHU
Disaggregation: logbook
Sex Denominator:Total
Population

2.Maternal Theratioofthenumberofmaternaldeaths per100,000 Numerator:No.ofMaternal 50%per LCRand Annual Thematernalmortalityratiois
MortalityRatio livebirthsperyear. Deaths 100,000 TCL,RHU themostwidelyusedmeasure
(MMR) LB logbook ofmaternaldeath.Itmeasures
Definitionofterms: Denominator:TotalNo.of obstetricriskinotherwords,
Livebirths theriskofawomandyingonce
Maternaldeathisthedeathofwomanwhilepregnantor sheispregnant.Itdoesnot
within42daysofterminationofpregnancy,irrespectiveof thereforetakeintoaccountthe
thedurationandthesiteofthepregnancy,fromanycause riskofbeingpregnant(i.e.
relatedtooraggravatedbythepregnancyorits fertility)inapopulation,which
management,butnotfromaccidentalorincidentalcauses. ismeasuredbythematernal
mortalityrateorthelifetime
risk.
3.InfantMortality Theratioofthenumberofdeathsamonginfants(below Numerator:No.ofinfant 17deaths LCRand Annual Measurestheriskofdying
Rate(IMR) oneyearofage)per1,000Livebirths deaths(belowoneyearof per1,000 TCL duringthefirstyearoflife.Itis
age) LB agoodindexofthegeneral
Definitionofterms: (NOH healthconditionofa
Denominator:TotalNo.of 2016) communitysinceitreflectsthe
InfantMortalityRate:Probabilityofdyingbetweenbirth livebirths changesintheenvironmental
andexactlyoneyearofage,expressedper1,000livebirths andmedicalconditionofa
community.

4.UnderFive Theprobabilityofdyingbetweenbirthandexactlyfive Numerator:No.ofdeaths 25.5 LCRand Annual
MortalityRatio yearsofage,expressedper1,000livebirths amongchildrenunder5 deaths TCL
yearsofage per1,000
LB(NOH
Denominator:TotalNo.of 2016)
livebirths
Data Reporting
5.Perinatal Isthenumberofdeathsoffetusesweighingatleast500g Numerator:NumberofFetal 18 LCRand Annual Theperinatalmortality
MortalityRate (or, when birth weight is unavailable, after 22 completed Deathsof28ormoreweeks Perinatal TCL,RHU indicatorplaysamajorrolein
weeksofgestationorwithacrownheellengthof25cmor gestation+Numberof Deaths logbook providingtheinformation
more),plusthenumberofearlyneonataldeaths,per1000 Newbornsdyingunder7 per1,000 neededtoimprovethehealth
totalbirths.Becauseofthedifferentdenominatorsineach daysofage) LB(NOH statusofpregnantwomen,new
component,thisisnotnecessarilyequaltothesumofthe 2016) mothersandnewborns.That
fetaldeathrateandtheearlyneonatalmortalityrate. Denominator:Numberof informationallowsdecision
LiveBirths+FetalDeathsof makerstoidentifyproblems,
28ormoreweeksgestation tracktemporal(relatedtotime)
andgeographicaltrends
X1000 (relatedtoplace)and
disparitiesandassesses
changesinthepublichealth
policyandpractice.Thisisthe
mostsensitivemeasurefor
maternalhealthandnewborn
care.

6.Neonatal Anyneonataldeathbetweenbirthupto28daysofage. Numerator:Noofneonatal 10Deaths LCRand Annual
mortalityrate deaths per1,000 TCL,RHU
LB(NOH logbook
Denominator:TotalNo.of 2016)
livebirths

7.NeonatalTetanus Anyneonataldeathbetween3and28daysofageinwhich Numerator:No.ofdeaths Lessthan LCRand Annual
MortalityRate thecauseofdeathisunknownorduetoneonataltetanus. duetoneonataltetanus 1case TCL,RHU
per1,000 logbook
Denominator:TotalNo.of livebirths
livebirths

3.4 ENVIRONMENTAL HEALTH
_____________________________________________________________________________________________________________________________________________________________
Data Reporting
1.Proportionof Referstohouseholdscoveredbyorhaveaccesstothe Numerator:TotalNo.of Annual

Householdswith followingimprovedtypesofdrinkingwatersources Householdswithaccess
accesstoimproved toimprovedorsafewater
orsafewatersupply Definitionofterms: supply
(LevelI,II,III) LevelI(PointSource)referstoaprotectedwell(shallow LevelI
anddeepwell),improveddugwell,developedspring,or LevelII
rainwatercisternwithanoutletbutwithoutadistribution LevelIII
system.
Denominator:TotalNumber
LevelII(CommunalFaucetSystemorStandpost)refersto ofHouseholds
asystemcomposedofasource,areservoir,apiped
distributionnetwork,andacommunalfaucetlocatednot
morethan25metersfromthefarthesthouse.Itis
generallysuitableforruralandurbanareaswherehouses
areclustereddenselyenoughtojustifyasimplepiped
watersystem
Note:ForreportingpurposesLevelIIsystemmayalso
includeacommunalfaucetconnectedtoLevelIIIwhere
groupofhouseholdsgettheirwatersupply.

LevelIII(WaterworksSystem)asystemwithasource,
transmissionpipes,areservoir,andapipeddistribution
networkforhouseholdtaps.Itisgenerallysuitedfor
denselypopulatedareas.ExamplesoftheseareMWSS
andwaterdistrictswithindividualhouseholdconnections.
Note:ForreportingpurposesLevelIIIsystemmayalso
includeaLevelIsystemwithpipeddistributionfor
householdtapservinggroupofhousingdwellingssuchas
apartmentsorcondominiums.
2.Proportionof Referstohouseholdswithflushtoiletsconnectedtoseptic Numerator:Totalno.of 91% Annual
Householdswith tanksand/orseweragesystemoranyotherapproved HouseholdswithSanitary (national)
SanitaryToilet treatmentsystem,sanitarypitlatrineorventilated toilet 96%
Facilities improvedpitlatrine. (urban)
Denominator:TotalNumber 86%
ofHouseholds (rural)
Data Reporting
3.Householdswith Referstohouseholdswithgarbagedisposalthrough Numerator: TotalNo.of 41%Metro Annual

satisfactorydisposal composting,burying,city/municipalsystem. Householdswithsatisfactory Manila
ofsolidwaste disposalofsolidwaste 20%other
Refersontheinformationcollectedonthesanitarystatus highly
oftwoaspectsofsolidwastemanagement(storageand Denominator:TotalNumber urbanized
collectionordisposal) ofHouseholds areas
4.Proportionof Referstohouseholdswhichsatisfythepresenceofthe Numerator:Totalno.of Annual
Householdswith followingbasicsanitationelements,namely: HouseholdswithComplete
CompleteBasic (1)accesstosafewater BasicSanitationFacilities
SanitationFacilities (2)availabilityofasanitarytoilet
(3)satisfactorysystemofgarbagedisposal Denominator:TotalNumber
ofHouseholds

5.Proportionof Referstotheratioofthenumberoffoodestablishments Numerator:Totalno.ofFood 100% Annual
FoodEstablishment withsanitarypermit. Establishmentswith
withSanitary SanitaryPermit
Permits Definitionofterms:
Denominator:Totalno.of
FoodEstablishmentEstablishmentwherefoodordrinks FoodEstablishments
aremanufactured,processed,stored,soldorserved,
includingthosethatarelocatedinvessels.Itreferstothe
totalnumberoffoodestablishmentswhichincludes
restaurants,sarisaristores,canteens,coffeeshops,
carinderia,refreshmentparlors,bakeries,waterrefilling
station,foodmanufacturing,bottling,dairyandcanning
establishments.

SanitaryPermitthecertificationinwritingofthecityor
municipalhealthofficerorsanitaryengineerthatthe
establishmentcomplieswiththeexistingminimum
sanitationrequirementsuponevaluationorinspection
conductedinaccordancewithPresidentialDecreesNo.522
and856andlocalordinances.

6.Proportionof Referstotheratioofthenumberoffoodhandlersissued Numerator:Totalno.ofFood 100% Annual
FoodHandlerswith withhealthcertificates. HandlersissuedHealth
HealthCertificates Certificates
Data Reporting
Definitionofterms: Denominator:TotalNo.of
FoodHandlers
FoodEstablishmentReferstothetotalnumberoffood
establishmentswhichincludesrestaurants,sarisaristores,
canteens,coffeeshops,carinderia,refreshmentparlors,
bakeries,waterrefillingstation,foodmanufacturing,
bottling,dairyandcanningestablishments

FoodHandlersReferstoapersonwhohandles,prepares,
servesfood,drinkoricewhocomesincontactwithany
cookingutensilsandfoodvendingmachines

HealthCertificatesacertificationinwriting,usingthe
prescribedform,andissuedbythemunicipalorcityhealth
officertoapersonafterpassingtherequiredphysicaland
medicalexaminationsandimmunizations

3.5 MATERNAL CARE
_____________________________________________________________________________________________________________________________________________________________
Data Reporting
1. Totalno.of No.ofdeliveries NumberofDeliveries

deliveries
2.Proportionof Theproportionofpregnantwomenwhohad4ormore Numerator: Numberof 90% (NOH RHU,TCL Monthly Anindicatorofaccessand
Pregnant prenatalvisits. pregnantwomenwith4or 2016) (BHSto utilizationofhealthcareduring
womenwith4 moreprenatalvisits RHU) pregnancy
ormore DefinitionofTerms:
prenatalvisits Denominator: Quarterly Itisstronglyencouragedthat
SignsofPregnancyaccordingtothreecategories: TotalPopulationx2.7% (RHUto the first prenatal visit is
a.Presumptive(1)Breastchanges,includingfeelingof nexthigher during the first trimester so
tenderness,fullness,ortinglingandenlargementor levels) that preventive, promotive
darkeningofareola;(2)Nauseaorvomitinguponarising; healthinterventions(suchas
(3)Amenorrhea;(4)Frequenturination;(5)Fatigue;(6) micronutrient
Uterineenlargementinwhichtheuteruscanbepalpated supplementation,screening
overthesymphysispubis;(7)Quickening(fetalmovement forcomplications)willbegiven
feltbythewoman);(8)Lineanigra(lineofdarkpigmenton towomenintheearliest
theabdomen);(9)Melasma(darkpigmentontheface); possibletime.
and(10)Striaegravidarum(redsteaksontheabdomen).

b.Probable(1)Serumlaboratorytestrevealingthe
presenceofhumanchorionicgonadotropin(hCG)
hormone;(2)Chadwickssign(vaginachangescolorfrom
pinktoviolet);(3)Goodellssign(cervixsoftens);(4)Hegar
ssign(loweruterinesegmentsoftens);(5)Sonographic
evidenceofgestationalsacinwhichcharacteristicringis
evident;(6)Ballottement(fetuscanbefelttoriseagainst
abdominalwallwhenloweruterinesegmentistapped
duringbimanualexamination);(7)BraxtonHicks
contractions(periodicuterinetightening);and(8)
Palpationoffetaloutlinethroughabdomen.

c.Positive(1)Sonographicevidenceoffetaloutline;(2)
FetalheartaudiblebyDopplerultrasound;and(3)
Palpationoffetalmovementthroughabdomen

Data Reporting
4ormoreprenatalvisitsmeansthatatleastonevisit
occursduringthefirsttrimester,oneduringthesecond
trimesterandatleast2visitsduringthethirdtrimester.If
visitsoccurredoutsidethecatchmentsRHU,thatvisit
shouldbecountedaspartoftheminimumrequirements.

Prenatalservicesinclude(1)completephysical
examinationofpregnantwomen(pregnancystatus)(2)
checkforpreeclampsia(3)checkforanemia(4)checkfor
syphilis(5)check/screenandtreatmentforSTIandHIV
status(6)respondtoobservedsignsorvolunteered
problems(7)givepreventivemeasures(8)adviceand
counselonfamilyplanning(9)checkonbirthand
emergencyplan(10)checkfornutritionalstatusand(11)
advocacyonbreastfeeding.

3.Proportionof Proportionofpregnantwomenimmunizedagainst Numerator:No.ofpregnant RHU Monthly AssessthelevelofTT
Pregnantwomen tetanus,havingatleasttwodosesoftetanustoxoidduring womengiven2dosesof (BHSto immunizationprotection
given2dosesof pregnancy. TetanusToxoid NSO RHU) amongpregnantwomen.
TetanusToxoid Quarterly
Denominator: (RHUto
TotalPopulationx2.7% nexthigher
level)
4.Proportionof ProportionofpregnantwomengivenTT2plusduringher Numerator:Numberof 80%(NOH Monthly AssessthelevelofTT
PregnantWomen lastpregnancy. pregnantwomengivenTT2 2016) (BHSto immunizationprotection
givenTT2plus plus RHU) amongpregnantwomen.
DefinitionofTerms: Quarterly
TT2plusincludes2nd,3rd,4thand5thdosesofTetanus Denominator: (RHUto
Toxoidgiventopregnantwomen. TotalPopulationx2.7% nexthigher
level)
5.Pregnantwomen Proportionofpregnantwomengivencompleteirontablet Numerator:Numberof 80% RHU Monthly Thereisahighprevalenceof
givencompleteiron withfolicacidsupplementation. pregnantwomengiven (BHSto anemiainpregnantmothers.
withfolicacid completeironwithfolicacid NSO RHU) Thisindicatorwilltellusif
supplementation DefinitionofTerms: supplementation Quarterly adequateironsupplementation
Completeirontabletwithfolicacidsupplementation (RHUto isgivenortakenbythe
refersto60mgofelementalironwith400mcgFolicacid, Denominator: nexthigher mother.
onceadayfor6monthsor180tabletsfortheentire TotalPopulationx2.7% level)
Data Reporting
pregnancyperiod.Theirontabletsreferredtoarethose
givenforfreetothemotherbytheRHUsandBHSsanddo
notincludeprescribedirontablets.Irontabletshouldbe
givenassoonaspregnancywasdiagnosed.Ifthepregnant
womendidnottakefullcourseof180tabletsshewillnot
beconsidered.

6.Proportionof Proportionofpostpartumwomengivenatleast2post Numerator:Numberofpost RHU Monthly Majorityofmaternalmorbidity
Postpartum partumvisits. partumwomengivenat (BHSto andmortalityoccursatthe
womenwithat least2postpartumvisits NSO RHU) postpartumperiod.Itis
least2postpartum DefinitionofTerms: Quarterly importantthatthis
visits Postpartumvisitsreferstovisitsseenbythe Denominator: (RHUto complicationbedetectedas
midwife/PHN/MHOathomeorattheclinictwiceormore Totalnumberofpopulation nexthigher soonaspossible.
thantwiceafterdeliverysuchthatfirstvisitshouldbe x2.7% level)
after24hoursupondeliveryandthesecondvisitwithin
oneweekafterdelivery.
Note:Pregnantwomenwhodeliveredinthehospitalis
alreadyconsideredseeninthefirstvisitwhichis24hours
upondelivery.
7.Postpartum Proportionofpostpartumwomengivencompleteiron Numerator:Numberofpost RHU Monthly Thereisahighprevalenceof
womengiven supplementation. partumwomengiven (BHSto anemiainpostpartumand
completeiron completeiron NSO RHU) lactatingwomen.
supplementation DefinitionofTerms: supplementation Quarterly
CompleteIronSupplementationrefersto60mgofFe (RHUto
with400mcgFolicacid,onceadayfor3monthsoratotal Denominator: nexthigher
of90tablets.Ifpostpartummotherdidnottakefullcourse Totalnumberofpopulation level)
of90tablets,shewillnotbeconsidered. x2.7%
8.Proportionof10 CompleteIronSupplementation refersto60mgofFe Numerator: 12.3% FHSIS Proxyindicatorforsuccessin
49yearsoldwomen with400mcgFolicacid,onceadayoncemenarchestarts (50%of interventiontodecreaseIron
givenIron anduntilonegetspregnant. Denominator: age deficiencyamongagegroup
supplementation TotalPopulationx24.6% group)of 1049yearsold
TPfor DatatakenfromIron
2013 DeficiencySurveyFNRI2008

9.Proportionof Proportionofpostpartumorlactatingwomengiven Numerator:Numberofpost 80% RHU Monthly Numerousstudieshaveshown
Postpartum VitaminAsupplementation partumwomengiven (BHSto thatpregnantand
womengiven VitaminAsupplementation NSO RHU) postpartum/lactatingwomen
Data Reporting
VitaminA DefinitionofTerms: Quarterly haveanincreaseriskofVitamin

supplementation VitaminAsupplementationrefersto200,000I.U.of Denominator: (RHUto ADeficiencyDisorder(VADD).
VitaminAcapsulewithin1monthafterdelivery TotalPopulationx2.7% nexthigher AnincreaseinVitaminA
level) concentrationofthemother,
resultstoanelevatedVitamin
Aconcentrationinher
breastmilkaswellasthe
VitaminAstatusofherbreast
fedchild.

10.Proportion Proportion of postpartum women who initiated Numerator:No.of RHU Monthly Successofbreastfeeding
Postpartum breastfeedingwithinonehouraftergivingbirth.Initiation postpartumwomeninitiated (BHSto initiationensurescontinuous
womeninitiated ofbreastfeedingisputtingthenewlydeliveredbabytothe breastfeedingwithin1hour NSO RHU) breastfeeding.Thisisoneway
breastfeeding mothers abdomen in prone position and allowing the aftergivingbirth Quarterly ofevaluatingwhetherbirth
within1hour newborntofindthemothersbreast(skintoskincontact) (RHUto attendantsadvocate
aftergivingbirth Denominator: nexthigher breastfeedingandimplement
Totalnumberofdeliveriesx level) MilkCodeinallfacilitybased
3%(x2.7%?) deliveries.

11.Percentageof Proportionofpregnantfemaleswhoaretestedforsyphilis Numerator:Numberof SSESS Biannual
pregnant usingRapidPlasmaReagin(RPR)orRapidDiagnosticTest pregnantfemaleswhoare Manualof
womentested (RDT) testedforsyphilisusingRPR Operations
forsyphilis orRDT (Appendix
Disaggregatebyagegroup(<15yo,15to17yo,18to24yo, A.1ICR);
>24yo) Denominator:Totalnumber FHSISTCL
ofpregnantfemaleswho
consultthehealthfacilityfor
thefirsttimeduringthat
reportingperiod

12. Percentageof Proportionofpregnantfemalesdiagnosedwithsyphilis Numerator:Numberof SSESS Biannual
pregnant whoaregivenPenicillin pregnantfemaleswhoare Manualof
womengiven givenonedoseofPenicillin Operations
Penicillin Disaggregatebyagegroup(<15yo,15to17yo,18to24yo, forsyphilis
>24yo)

Data Reporting
Denominator:Totalnumber (Appendix
ofpregnantfemalesare A.1ICR);
positiveforTPHA/TPPA;OR FHSISTCL
RDT;ORRPRtiterof>1:8
dilution

3.6 FAMILY PLANNING
_____________________________________________________________________________________________________________________________________________________________
Data Reporting
1.Contraceptive Theproportionofmarriedwomenofreproductiveage Numerator: 65%(NOH Family Monthly Thisindicatorisusefulfor
PrevalenceRate (1549 years of age) who are using (or whose partner is Numberofmarriedwomen 2016) Planning (BHSto measuringutilizationofFP
formodernFPuse using)anymodernFPmethodatagivenpointintime. ofreproductiveagewhoare TCL RHU) methods.Itisacomplementary
using(orwhosepartneris Quarterly outputindicatortototal
using)amodernFPmethod NSO (RHUto fertilityrate.
atagivenpointintime nexthigher
level) Populationbasedsample
Denominator: surveysprovidethemost
Numberofmarriedwomen comprehensivedataon
ofreproductiveagewhoare contraceptivepracticesince
eligibletopractice theyshowtheprevalenceofall
contraception(Total methods,includingthosethat
Populationx12.325%) requirednosuppliesormedical
services.Estimatesmayalsobe
14.5x85%=12.325% obtainedbysmallerscaleor
morefocusedsurveysandby
addingrelevantquestionsto
surveysonothertopics(e.g.
healthprogramprevalenceor
coveragesurveys).

Recordskeptbyorganized
familyplanningprogramare
anothermainsourceof
informationabout
contraceptivepractice.Such
recordsarecrucialtoeffective
monitoringandmanagement
ofprogram,andtheyhavethe
potentialtoprovidetimely
updatesanddetailedtrend
informationaboutnumbers
andcharacteristicsofprogram
Data Reporting
clients. Programstatisticshave
theseriousdrawback,however,
ofexcludingtheuseof
contraceptionobtainedoutside
theprogram,includingmodern
methodssupplies
2. Contraceptive Theproportionmarriedwomenofreproductiveage(1549 Formula Thisindicatorisusefulfor
Prevalence yearsofage)whoareusing(orwhosepartnerisusing)any measuringutilizationofFP
Ratefor modernFPmethodatagivenpointintime. Numerator: methods.Itisacomplementary
ModernFamily No.ofWomenin outputindicatortototal
Planning DefinitionofTerms: ReproductiveAge1549 fertilityrate.
Methoduseof yearsusingModernFamily
womenin Modern Family Planning Method include Female Planning(orwhosepartner Populationbasedsample
reproductive Sterilization/BTL and Male Sterilization/Vasectomy, usesModernFamily surveysprovidethemost
age. intrauterine devices IUD, oral pills, injectables and Planning)atanygivenperiod comprehensivedataon
implants. NFP Methods include Cervical Mucus Method oftime. contraceptivepracticesince
(CCM), Basal Body Temperature (BBT), Symptothermal theyshowtheprevalenceofall
Method (STM), Standard Days Method (SDM) and Denominator: methods,includingthosethat
Lactational Amenorrhea Method (LAM). Surgical TotalNo.ofwomenin requirednosuppliesormedical
sterilization (Female and Male Sterilization) is done those reproductiveage1549 services.Estimatesmayalsobe
coupleswhoreachedtheirdesirednumberofchildren. years. obtainedbysmallerscaleor
morefocusedsurveysandby
Womenofreproductiveagerefertoallwomenaged1549 addingrelevantquestionsto
yearsold. surveysonothertopics(e.g.
healthprogramprevalenceor
Eligiblepopulationorwomenofreproductiveagewhoare coveragesurveys).
atriskofgettingpregnantare:
Recordskeptbyorganized
sexuallyactive, familyplanningprogramare
fecund anothermainsourceof
notpregnantandmenstruating informationabout
contraceptivepractice.Such
Excludingarethewomenwhohaveunderwent: recordsarecrucialtoeffective
monitoringandmanagement
hysterectomy ofprogram,andtheyhavethe
bilateralsalpingooophorectomy, potentialtoprovidetimely
bilateraltuballigation,and updatesanddetailedtrend
informationaboutnumbers
Data Reporting
husbandsorpartnerswhounderwentVasectomy andcharacteristicsofprogram
clients.Programstatisticshave
theseriousdrawback,however,
ofexcludingtheuseof
contraceptionobtainedoutside
theprogram,includingmodern
methodssupplies

3. No.ofCurrent CurrentUsers(CU)areFPclientswhohavebeencarried FormulaforCUatEndof
Users overfromthepreviousmonthsafterdeductingthedrop Month/Quarter
outsofcurrentmonthandaddingthenewacceptorsof
thepreviousmonthandaddingtheOtherAcceptorsofthe =CUofpreviousmonth
currentmonth
Restarter(RS) +NewAcceptorofprevious
ChangingMethod(CM) month
ChangingClinic(CC) +Otheracceptorsofpresent
month

Dropoutofpresentmonth
4. No.ofNew NewAcceptor(NA)aclientusingacontraceptivemethod
Acceptors forthefirsttimeorhasneveracceptedanyModernFamily
Methodwhoisnewtotheprogram

5. No.ofDropouts Dropouts Ifaclientfailstoreturnforthenextservice
dateorotherconditions(e.g.BSO,Hysterectomy),sheis
consideredadropout.Theserviceprovidershouldhave
donevalidationpriortodroppingoutoftheclient.

3.7 CHILD CARE
_____________________________________________________________________________________________________________________________________________________________

Data Reporting
1.Proportionof AninfantwhohasreceivedBCGvaccineanytimeafterbirth Numerator:Numberof 90% Monthly BasisforcomputationofFIC,
InfantsgivenBCG beforereachingoneyearofage. infantsgivenBCG Children (BHSto numberofunimmunized
Vaccine <1 RHU) children,trackingdefaulters,
Denominator: TCL Quarterly accesstoimmunization.
TotalPopulationx2.7% (RHUto
NSO nexthigher
level)

2.Proportionof Aninfantwhoreceived(Pentavalent1,Pentavalent2or Numerator:Numberofinfant 90% Monthly BasisforcomputationofFIC,
Infantsgiven Pentavalent3)beforereachingoneyearold. givenPentavalent1/ Children (BHSto numberofunimmunized
Pentavalent1, Pentavalent2/Pentavalent3 <1 RHU) children,trackingdefaulters,
Pentavalent2, Pentavalentvaccinereferstothecombinationvaccineof TCL Quarterly accesstoimmunization.Assess
Pentavalent3 DPTHepBHinfluenzatypeB(HiB) Denominator: (RHUto populationimmunityineach
vaccines TotalPopulationx2.7% NSO nexthigher cohortofchildrenborn.
level)

3.Proportionof AninfantwhoreceivedspecificOPVantigens(eitherOPV1, Numerator: Numberofinfant 90% Monthly BasisforcomputationofFIC,
InfantsgivenOPV1, OPV2,orOPV3)beforereachingoneyearold givenOPV1/OPV2/OPV3 Children (BHSto numberofunimmunized
OPV2,OPV3 <1 RHU) children,trackingdefaulters,
Denominator: TCL Quarterly accesstoimmunization.
NSO nexthigher Mainindicatorforthe
level) eradicationofPolio

4.Proportionof Aninfantwhoreceived1stdoseofHepatitisBvaccine Numerator:Numberofinfant 65% Monthly BasisforcomputationofFIC,
Infantsgiven within24hoursafterbirth givenHepaB1w/in24hours Children (BHSto numberofunimmunized
HepatitisB1within afterbirth <1 RHU) children,trackingdefaulters,
24hoursafterbirth TCL Quarterly accesstoimmunization.
Denominator: (RHUto
TotalPopulationx2.7% NSO nexthigher
level)
5.Proportionof Aninfantwhoreceived1stdoseofHepatitisBvaccinemore Numerator: Numberofinfant 90% Monthly BasisforcomputationofFIC,
Infantsgiven than24hoursafterbirth givenHepaB1morethan24 Children (BHSto numberofunimmunized
Data Reporting
HepatitisB1more hoursafterbirth <1 RHU) children,trackingdefaulters,
than24hoursafter TCL Quarterly accesstoimmunization.
birth Denominator: (RHUto
TotalPopulationx2.7% NSO nexthigher
level)

6.Proportionof AninfantwhoreceivedonedoseofMeaslescontaining Numerator: Numberof911 90% Monthly BasisforcomputationofFIC,
Infantsgiven vaccineat911monthsold.Thisshallbereferredtoasthe mos.oldinfantgiven Children (BHSto numberofunimmunized
Measlescontaining 1stMeaslesContainingVaccine(MCV1) Measlescontaining <1 RHU) children,trackingdefaulters,
vaccine(MCV1) vaccine(MCV1) TCL Quarterly accesstoimmunization.Assess
(RHUto populationimmunityineach
Denominator: NSO nexthigher cohortofchildrenborn.
TotalPopulationx2.7% level)

7.Proportionof Achild1215monthsofagewhoreceivedonedoseof Numerator: Numberof 90% Monthly BasisforcomputationofFIC,
Childrengivena MMR.Thisshallbereferredtoasthe2nddoseofthe childrengivenMMR Children (BHSto numberofunimmunized
doseofMeasles Measlescontainingvaccine(MCV2) <1 RHU) children,trackingdefaulters,
MumpsRubella Denominator: TCL Quarterly accesstoimmunization.Assess
Vaccine TotalPopulationx2.7% (RHUto populationimmunityineach
(MMR)(MCV2) NSO nexthigher cohortofchildrenborn.
level)

8.Proportionof Aninfantwhoreceivedeither: Numerator: Numberofinfant 90% Monthly Basisforcomputationforthe
infantsgiven givenRotavirusVaccine Children (BHSto totalpopulationimmunityfora
Rotavirusvaccines OptionA:2doseregimenofrotavirusvaccineat6weeks <1 RHU) certainbirthcohort
32weeksofage Denominator: TCL Quarterly
or TotalPopulationx2.7% (RHUto (Rota1,Rota2)
OptionB:3doseregimenofrotavirusvaccineatspecific nexthigher Or
recommendedschedule level) Proportionofinfantsgiven
Rotavirusvaccines(Rota1,Rota
2,Rota3)
9.Proportionof AninfantwhoreceivedPneumococcalConjugateVaccines Numerator: Numberofinfant 90% Monthly Basisforcomputationforthe

infantsgiven (PCV1,PCV2,PCV3)beforereaching1yearold givenPCV1/PCV2/PCV3 Children (BHSto totalpopulationimmunityfora
Pneumococcal <1 RHU) certainbirthcohort
ConjugateVaccines TCL Quarterly
Data Reporting
(PCV1,PCV2,PCV Denominator: (RHUto
3) TotalPopulationx2.7% nexthigher
level)
10.Proportionof Aninfantwhoreceived1doseofBCG,3doseseachof Numerator:No.ofFully 90% Monthly Anoverallprogramindicatorto
FullyImmunized OPV,3doseseachofPentavalentvaccinesand1doseof ImmunizedChild (Program Children (BHSto assesstheproportionoffull
Child Measlescontainingvaccinebeforereachingoneyearold. yearly <1 RHU) complementofimmunization
Denominator: target) TCL Quarterly duringthefirstyearoflife.
NSO nexthigher
level)
11.Proportionof Achild12to23monthsofagewhoreceived1doseofBCG, Numerator:No.of Monthly Basisforcomputationforthe
Completely 3doseseachofOPV,3doseseachofPentavalentvaccines CompletelyImmunizedChild Children (BHSto totalpopulationimmunityfora
ImmunizedChild and1dosesofMeaslescontainingvaccines <1 RHU) certainbirthcohort.
Denominator: TCL Quarterly
NSO nexthigher
level)
12.Proportionof Referstoachildwhose: Numerator: Monthly TetanusToxoidImmunizationis
ChildProtectedat (1)Motherhasreceived2dosesofTTduringthis TotalNo.ofChildrenwhose Children (BHSto giventopregnantwomenin
Birth(CPAB) pregnancy,providedTT2wasgivenatleastamonth mothersweregivenatleast <1 RHU) ordertoprotectthenewborn
priortodelivery,or TT2ormore TCL Quarterly andherselffromtetanus.
(2)Motherhasreceivedatleast3dosesofTTanytime (RHUto
priortopregnancywiththischild Denominator: nexthigher Percentofprotectedatbirth
TotalNo.oflivebirths level) (PAB)isasupplemental
methodofdetermining
coverageprotection
(particularlywhereTT2+is
unreliableandwhereDTP1
coverageishigh).Tomonitor
PABduringDTP1visits,health
workersrecordwhetherinfants
wereprotectedatbirthbythe
mothersTTstatus.%PABis
thenestimatedas:numberof
infantsprotecteddividebythe
totalnumberofbirths
13.Proportionof AChildwhowasexclusivelybreastfed frombirthto6 Numerator: 60%by ExclusiveBFprovidesoptimum
Data Reporting
Infantsexclusively monthsofage.Exclusivebreastfeedingmeansnoother TotalNo.of Infants 2010 Monthly nutritionforthefirst6months
breastfeduntil6th food(includingwater)otherthanbreastmilk.Dropsof exclusivelyBreastfeduntil6th Children (BHSto oflifeandthenumberone
month prescribedvitaminsandmedicationwithindicationgiven month 70%by <1 RHU) preventivestrategytosave
whilebreastfeedingisstillexclusivelybreastfed. 2015 TCL Quarterly livesofbelowfivechildren.
Denominator: (RHUto Thisindicatoralsodetermines
TotalPopulationx1.35% nexthigher theprogressofBFpracticefor
level) programplanningandpolicy
directionandbasisforresearch
agendatoimproveBFpractice
inthecountrytoassessthe
implementationofEO51
14.Proportionof Complementaryfoodsandfoodsgivenstartingat6months Numerator:Infants68 90%by Monthly Thiswilldeterminecontinued

infants68months tocomplimentbreastfeeding monthswhoreceived 2010 Children (BHSto breastfeedingandtimely,
ofagewhoreceived solid,semisolidorsoft <1 RHU) appropriatecomplimentary
solid,semisolidor foodsduringtheprevious 95%by TCL Quarterly feedingtopreventunder
softfood day 2016 (RHUto nutrition
nexthigher
Denominator:No.ofLive level)
births
15.Proportionof Thisreferstoinfantsreferredfornewbornscreening. No.ofInfantsreferredfor 100% Monthly
Infantreferredfor Referralslipsmaybeused. newbornscreening Children (BHSto
newbornscreening <1 RHU)
Note:NBSReferralis48hoursofbirthto72hours TCL Quarterly
(RHUto
nexthigher
level)
16.Infant/Children ReferstoInfant/ChildrengivenVitaminAsupplementation. Numerator:No.of Monthly
givenVitaminA Infant/Children Children (BHSto
supplementationby RecommendedDosage: givenVitaminA 90%(NOH <1 RHU)
Agegroup 611monthsold1doseof100,000I.U.Onecapsuleis supplementation 2016) TCL Quarterly
givenanytimeduringthe611monthsbutusuallygivenat forage (RHUto
611 9monthsduringthemeaslesimmunization. Denominatorfor611mos: group NSO nexthigher
1223 TotalPopulationx1.35% under6 level)
2435 1259monthsold200,000I.U.Dosageanddurationis1 yearsof

3647and capsuleeverysixmonths. Denominatorfor1259mos: age
4859monthsold TotalPopulationx10.8%
Data Reporting
17.Infant/ Referstoinfants611monthsold givenIrondrops, 1223 Numerator:No.of Monthly
ChildrengivenIron monthsoldgivenIronsyrup. infant/Childrenmonthsold (BHSto
supplementation givenIron RHU)
Quarterly
Denominatorfor611mos: (RHUto
TotalPopulationx1.35% nexthigher
level)
Denominatorfor1223mos:
TotalPopulationx2.7%

18.Children1259 Referstochildren1259monthsoldgivendeworming No. ofchildren1259months Children Monthly
mos.oldgivende tablet/syruptwiceayear oldgivendeworming <1 (BHSto
worming tablet/syrup TCL RHU)
tablet/syrup Quarterly
(RHUto
nexthigher
level)

19.Infant611 Referstoinfants611monthsoldconsumedmicronutrient Numerator:No.ofinfant6 Children Monthly
monthsconsumed powders 11monthsoldgivenMNP <1 (BHSto
60sachetsof TCL RHU)
micronutrient DefinitionofTerms: Denominator:Total Quarterly
powders(MNP) MicronutrientPowderreferstopremixvitaminsand Populationx1.35% (RHUto
mineralsinpowderform. nexthigher
Everychildwillreceiveatotalof60sachetsoveraperiod level)
of6months
20.Children1223 Referstochildren1223monthsoldconsumed Numerator:No.ofchildren TCL
months micronutrientpowder. 1223monthsoldgiven
consumed120 MNP
sachetsof DefinitionofTerms:
Micronutrients MicronutrientPowderreferstopremixvitaminsand Denominator:Total
powder(MNP) mineralsinpowderform. Populationx2.7%
Everychildwillreceive60sachetsevery6monthsfora
totalof120sachetsinayear.
21.SickChild/ Referstoachild/children611and1259monthsoldseen Numberofsickchildren6 Sick Monthly
Children611mos. andidentifiedassickchild. 11,1259oldseen Child (BHSto
and1259mos. Care RHU)
Data Reporting
(disaggregatedby Definitionofterms: TCL Quarterly
sex) SickChildrenarethosechildrenwithatleastonethe (RHUto
followingcategories: nexthigher
Severepneumonia(referstopresenceofanygeneral level)
dangersignorchestindrawingorstridorincalmchild)
Severepersistentdiarrhea(referstoanepisodeofsoftto
waterystoolslastingmorethan14days)
Measles(Historyoffeverorhottotouch;generalized
nonvesicularrashof3ormoredaysdurationandat
leastoneofthefollowing:cough,coryzaorconjunctivitis
Severelyunderweight(referstochildrenwhoseweight
areclassifiedasverylowbelownormal)

22.No.ofSick Anysickchild/childrengivenVitaminAcapsule.Dosageof Numerator:Numberofsick 100% Sick Monthly Vit.Aisgiventohighrisk
Childrenbyage VitaminAfor611montholdinfantis100,000IU,while12 children611/1259 Child (BHSto childrenbecauseithelpsre
givenVitaminA to59montholdinfantsaregiven200,000IU(1capsule monthsgivenVitaminA Care RHU) establishbodyreservesdrained
capsule every6months). capsule TCL Quarterly bychronicorrepeated
(RHUto infections&protectsthe
611mos. Denominator:Numberofsick nexthigher childrenagainstseverityor
and children611,1259 level) subsequentinfections.Italso
1259mos. monthsoldseen reducesthecomplicationsofan
existingmeaslesinfection&
(disaggregatedby lowersmeaslesmorbidity&
sex) mortality.
23.Infants Thisreferstoinfants26monthsoldseenwithlowbirth No.ofinfants26monthsold Children Monthly

withlowbirth weight(weightatbirthislessthan2.5kilograms) seenwithlowbirth <1 (BHSto
weightseen weight TCL RHU)
(disaggregated Quarterly
bysex) (RHUto
nexthigher
level)
24.Infantswith Thisreferstolowbirthweight(LBW)infants26months Numerator:No.ofinfants2 100% Children Monthly Giveironsupplementstolow
lowbirthweight oldwhoseweightatbirthislessthan2.5kilogramsand 6mos.oldwithlowbirth <1 (BHSto birthweightinfantsat2
giveniron wasgivenironsupplementation.Dosageis0.3mloncea weightgiveniron TCL RHU) months,astheyarebornwitha
daytostartattwomonthsofageuntil6monthswhen supplementation Quarterly lowerironsupplyandareat
Data Reporting
supplementation complementaryfoodsaregiven.(Preparationis15mg. (RHUto highriskforirondeficiency
(disaggregated elementaliron/0.6ml).Needtoassessforfurther Denominator:No.ofinfants nexthigher evenifexclusivelybreastfed.
bysex) management 26mos.oldseenwithlow level)
birthweight

prevalenceofLBW=19.6%
25.AnemicChildren Thisreferstoanemicchildren6to59monthsoldseen. No. ofanemicchildren611 Sick Monthly
611monthsand monthsand259monthsold Child (BHSto
1259months seen Care RHU)
old TCL Quarterly
seen (RHUto
(disaggregated nexthigher
bysex) level)
26.AnemicChildren Thisreferstoanemicchildren6to59monthsoldgiven Numerator:No.ofanemic Sick Monthly
611monthsand ironsupplementation(syrup).Dosageis1tsp.onceaday children611monthsand Child (BHSto
1259months for3monthsor30mg.onceaweekfor6monthswith 1259monthsoldgiven Care RHU)
old supervisedadministration. ironsupplementation TCL Quarterly
giveniron (RHUto
Giveapproximately0.6ml,23timesadayfor3months Denominator:Numberof NSO nexthigher
supplementation anemicchildren6 level)
(disaggregated 11monthsand1259 ITR
bysex) monthsoldseen
27.Diarrheacases Referstochildren059monthsoldseenwithdiarrhea. No.ofdiarrheacases059 Sick Monthly
059months monthsoldseen Child (BHSto
oldseen Care RHU)
(disaggregated TCL Quarterly
bysex) (RHUto
ITR nexthigher
level)
IMCI
form
28Diarrheacases Referstochildren059monthsoldwithdiarrheagivenOral Numerator:No.ofdiarrhea Sick Monthly Identificationofcommonly
059monthsold RehydrationSaltonly. cases059monthsold Child (BHSto usedrehydrationsolutionin
givenORSonly givenORS Care RHU) diarrheamanagementfor
(disaggregated Definitionofterms: TCL Quarterly planning/budgetingpurposes
bysex) OralRehydrationSaltisthenonproprietarynamefor Denominator:No.ofdiarrhea (RHUto
balancedglucoseelectrolytemixtureusefortreatmentof cases059monthsold ITR nexthigher
Data Reporting
clinicaldehydration. seen level)
IMCI
form
29.Diarrheacases Referstochildren059monthsold withdiarrheagiven Numerator:No.ofdiarrhea Sick Monthly Identificationofcommonly
059monthsold ORS/ORTwithzinc.Dosageforchildrenlessthan6months cases059monthsold Child (BHSto usedrehydrationsolutionin
givenORS/ORT is10mgelementalZn/dayandforchildrenmorethan6 givenORS/ORTwithzinc Care RHU) diarrheamanagementfor
andzinc monthsis20mgelementalZinc/dayx1014days. TCL Quarterly planning/budgetingpurposes
(disaggregated Denominator:No.ofdiarrhea (RHUto
bysex) Definitionofterms: cases059monthsold ITR nexthigher
OralRehydrationTherapyreferstoincreaseinfluidintake seen level)
andcontinuousfeeding.(advice) IMCI
form
30.Pneumonia Referstochildren059monthsoldseenwithpneumonia No.ofpneumoniacases059 Sick Monthly
cases059mos. monthsoldseen Child (BHSto
oldseen Care RHU)
(disaggregated TCL Quarterly
bysex) (RHUto
ITR nexthigher
level)
IMCI
form
31.Pneumonia Referstochildren059monthsoldseenwithpneumonia Numerator:No.of Sick Monthly
cases059mos. andgivenantibiotictreatment pneumoniacases059 Child (BHSto
oldgiven monthsoldgiven Care RHU)
treatment treatment TCL Quarterly
(disaggregated (RHUto
bysex) Denominator:No.of ITR nexthigher
pneumoniacases059 level)
monthsoldseen IMCI
form

3.8 DENTAL HEALTH
_____________________________________________________________________________________________________________________________________________________________
Sourceof Frequency
Data ofReporting
1.OrallyFit Proportionofchildren12to71monthsoldandare Numerator:No.oforallyfit ITR Quarterly Tomeasuretheoutcomeof
Children(1271 orallyfitduringagivenpointintime children1271monthsold (RHUto totalhealthcareofchildrenless
monthsold) Oral nexthigher than6yearsoldforplanning
(disaggregated DefinitionofTerms: Denominator: Health level) andevaluation.
bysex) OrallyFitChildrenreferstochildrenwhomeetallof TPx13.5% Form2
thefollowinguponoralexaminationand/orcompletion (Consolidated
oftreatment: OralHealth
(1)carriesfreeordecayedteethfilled(permanent Statusand
fillings) Services
(2)hashealthygums Report)
(3)nooraldebris,and
(4)nodentofacialanomalythatlimitsnormalfunction NSO

2.Children1271 Proportionofchildrenwhoseagesrangesfrom12to71 Numerator:Numberof ITR Quarterly Tomeasuretheoutcomeof
monthsold monthsoldandwereprovidedwithBasicOralHealth children (RHUto totalhealthcareofchildrenless
providedwith Care(BOHC) 1271monthsoldprovided Oral nexthigher than6yearsoldforplanning
BasicOral withBOHC Health level) andevaluation.
HealthCare Definitionofterms Form2
(BOHC) BasicOralHealthCare(BOHC)providedtochildren12 Denominator:
(disaggregated 71monthsoldreferstooneormoreofthefollowing TPx13.5% NSO

bysex) services:
(1)OralExamination
(2)80%AttendancetoSupervisedToothBrushing
(3)AltraumaticRestorativeTreatment(ART)
(4)OralUrgentTreatment(OUT)
removalofunsavableteeth,or
referralofcomplicatescases,or
treatmentofpostextractioncomplications,or
drainageoflocalizedoralabscess

3.Adolescentand Proportionofadolescentsandyouthwhoseages Numerator:Numberof ITR Quarterly Tomeasuretheoutcomeof
Youth(1024 rangesfrom10to24yearsoldandwereprovidedwith AdolescentandYouth (RHUto totalhealthcareofadolescent
yearsold BasicOralHealthCare(BOHC) (1024yearsold)provided Oral nexthigher andyouthforplanningand
Sourceof Frequency
Data ofReporting
providedwith withBOHC Health level) evaluation.
BasicOral Definitionofterms Form2
HealthCare BasicOralHealthCare(BOHC)providedtoAdolescents Denominator:
(BOHC) andYouth(1024yearsold)referstooneormoreof TPx30%(2008) NSO
(disaggregated thefollowingservices:
bysex) (1)OralExamination
(2)Educationandcounselingonhealtheffectsof
tobacco/smoking,diet,andoralhygiene
4.Pregnant Proportionofpregnantwomenwhowereprovided Numerator:Numberof ITR Quarterly Tomeasuretheoutcomeof
women withBasicOralHealthCare(BOHC) PregnantWomenprovided (RHUto totalhealthcareofpregnant
providedwith withBOHC Oral nexthigher womenforplanningand
BasicOral Definitionofterms Health level) evaluation.
HealthCare BasicOralHealthCare(BOHC)providedtoPregnant Denominator: Form2
(BOHC) Womenreferstooneormoreofthefollowing TPx2.7%
services: NSO
(1)OralExamination
(2)Scaling
(3)PermanentFilling
(4)GumTreatment

5.OlderPersons Proportionofolderpersonages60yearsoldandabove Numerator:Numberof ITR Quarterly Tomeasuretheoutcomeof
60yearsoldand whowereprovidedwithBasicOralHealthCare(BOHC) OlderPersonsprovided (RHUto totalhealthcareofolderperson
aboveprovided withBOHC Oral nexthigher forplanningandevaluation.
withBasicOral Definitionofterms Health level)
HealthCare BasicOralHealthCare(BOHC)providedtoOlderPerson Denominator: Form2
(BOHC) referstooneormoreofthefollowingservices: TPx6.9%
(disaggregated (1)OralExamination NSO
bysex (2)Extraction
(3)GumTreatment

3.9 F I L A R I A S I S
_____________________________________________________________________________________________________________________________________________________________
Sourceof Frequency
Data ofReporting
1.Prevalencerate Microfilariaprevalence(mf%):Proportionofblood Numerator:No.of Prevalenceof Filariasis Annual Baselineis9.7casesper1,000
ofmicrofilariain slides(20microL)foundpositiveformicrofilaria. individuals microfilariaof<1% Registry population(DOHNCDPC1998)
endemic whoseslidesarepositive
provinces formf (Globaland (44
NationalStandard) provinces)
Baselineshows0provincehas
<1%
individualsexaminedfor
mf

N/Dx100=MFR
2.Microfilaria MFD:averagenumberofmicrofilariainslides Numerator:Totalcountof Reduce Filariasis Annual
density(MFD)in positiveformicrofilariaexpressedaspermLof microfilariaintheslides microfilaria Registry
endemic capillaryblood foundpositivex50 densityinendemic
municipalities (presuming20microliter municipalitiesto0
100X50/10=50 perslide)

Denominator:Numberof
slidesfoundpositive

3.MassDrug MDAcoverageusingeligiblepopulation/target Numerator:No.ofpersons 85%coveragefor Filariasis Annual Baselineof82%masstarget
Administration populationinendemicprovincesProportionof givenMDA eligiblepopulation Registry coveragein30endemicareas
Coverageamong targetpopulationcoveredbyMDAduringthe (DOHNCDPC)
eligiblepopulation reportingyear Denominator:Total
Populationaged2yrsand
aboveinimplementingunits
forMDA
(eligiblepopulation)

4.MassDrug MDAcoverageamongtotalpopulation. Numerator:No.ofpersons 65%coveragefor Filariasis Annual
Administration givenMDA totalpopulation Registry
Coverageamong
totalpopulation Denominator:Total
Population
Sourceof Frequency
Data ofReporting
5.ClinicalRateof Proportionofpeopleexamined showingthe Numerator:No.ofpatients Reduce Filariasis Annual
Filariasis chronicmanifestationofLFex.(Hydrocele, withLymphedemaor adenolymphangitis Registry
Lymphedema,Elephantiasis(lowerandupper HydroceleorElephantiasisor attackstooneper
extremities,breast,penisandscrotum)and Chyluria year
Chyluria
Denominator:Total
Numberofpeopleexamined

3.10 L E P R O S Y
_____________________________________________________________________________________________________________________________________________________________
Sourceof Frequency
Data ofReporting
1.Leprosy Prevalenceisthenumberofleprosycases Numerator:No.ofLeprosy Lessthanone Leprosy Monthly Prevalencerate.Ifthe
PrevalenceRate registeredatagivenpointintimeandthe Cases caseper10,000 Registry (BHSto prevalencerateishigh
prevalencerateisper10,000totalpopulation. Population RHU) (prevalencerate>1per10000
Quarterly population),thiscanindicate
Acaseofleprosyisapersonpresentingclinical Denominator:Total (RHUto severalpossibilities:(1)high
signsofleprosy(withorwithoutbacteriological Population nexthigher transmissioninthedistrict(2)
examination)whohasyettocompleteafullcourse level) resultofleprosyelimination
oftreatment.Apatientwhohascompletedafull campaigns(3)resultofover
courseoffixeddurationMDT(6dosesforPBand12 diagnosis(4)resultofrecycling
dosesforMB)iscured. ofoldpatients,or(5)standard
MDTregimenisnotfollowedor
AnMBpatientwhohasnotcollectedtreatmentfor lowcurerate(accumulationof
6consecutivemonthsandaPBpatientwhohasnot patients)(6)shouldincrease
collectedtreatmentfor3consecutivemonthsare becauseofthepopulation
considereddefaulterandshouldstartretreatment factor.
butnotremovedfromtheprevalence. Italsosignifiesmagnitudeof
thecaseloadsparticularly
Includes: hiddencasesinthecommunity
1) stillneedingtreatment(includingreturnafter
default)
2) transin
3) Newcases
4) defaulted

Excludes:
1) Treatmentcompleted
2) Casescured
3) Transout
4) Died

Sourceof Frequency
Data ofReporting
2.Casedetection Detectionanddetectionrate.Numberofcases Numerator:No.ofNewly Benchmark: Leprosy Monthly Detectionrate.Ifthedetection
rate newlydetectedduringthereportingperiodand Detectedcasesduring Lessthan5%from Registry (BHSto rateishigh,thepossibilitiesare
nevertreatedbefore.Thedetectionrateisper reportingperiod previousyear RHU) thesameasthefirstfourabove
100,000totalpopulation. Quarterly pluscommunityawareness
Denominator:Total (RHUto maybeincreasing.Ifthetrend
Population nexthigher isdecreasing,thefollowing
level) possibilitiesshouldbe
considered:1)transmissionis
decreasing,2)MDTservicesare
becominglessactive,or3)
imageofleprosyhasbeen
damaged.

Regarding(2)MDTservicesare
becominglessactive,itis
naturaltosomeextentthatthe
detectiondecreasesafter
intensifiedcasefinding
activitieslikeleprosy
eliminationcampaigns.Review
iftherestoftheservicesare
notdeteriorating.Regarding(3)
imageofleprosyhasbeen
damaged,IECactivitiescould
haveanegativeimpactonthe
imageofleprosy.ReviewIEC
materialsandinterview
patientsandthecommunity.

Themostusefulindicatorsfor
estimatingthemagnitudeof
theproblemandthelevelof
ongoingtransmission.Case
detectionisalsoessentialon
calculatingdrugneeds.

Sourceof Frequency
Data ofReporting
3.Proportionof Thenumberofnewlydiagnosedpatientsbelowthe Numerator:No.ofLeprosy Benchmark: Leprosy Monthly Givesanindicationofongoing
newlydetected ageof15dividedbythenumberofnewlydetected casesbelow15yearsof Lessthan3%from Registry (BHSto transmission
leprosycases patientsforwhomageisrecorded. age previousyear RHU)
below15years Quarterly
ofage Denominator:No.ofnewly (RHUto
detectedLeprosycases nexthigher
level)

4.Proportionof MethodofcalculationofpercentagewithGrade2 Numerator:No.ofLeprosy Benchmark: Leprosy Monthly Givesanindicationofthedelay
newlydetected disabilityinleprosyiscausedbydamageofthe caseswithGrade2 Lessthan5%from Registry (BHSto betweenonsetofsymptoms
caseswith peripheralnerves disability previousyear RHU) andthestartoftreatmentand
gradetwo Quarterly theseverityofthediseasein
disability Denominator:No.ofnewly (RHUto newcases
detectedLeprosycases nexthigher
level)
5.Curerate Curerate.Numberofpatientswhohavereceiveda Numerator:No.ofLeprosy 100% Leprosy Monthly Curerate,defaulterrate.Cure
(treatment completetreatment(6blistersforPBpatientsand casesgotcured Registry (BHSto rateshouldbeascloseto100%
completion) 12blistersforMBpatients)inagroupofpatients RHU) aspossibleitshouldbe
detectedduringagivenperiod69monthsforPB Denominator:TotalNo.of Quarterly ensuredthatallpatients
patientsand1218monthsfortheMBpatientsfor Leprosycases (RHUto registeredfortreatmentare
thecohortanalysis). nexthigher cured.Lowcurerates,high
level) defaulterratesandhigh
Tofacilitatethecalculationoftheaveragecure proportionofpatientsstillon
rate,itisrecommendedtotakethesameperiodof treatmentafterhaving
oneyearbeforethereportperiod,aswellasforPB completedthestandard
andMBpatients,dividedbythenumberofpatients regimencanindicatefollowing
detectedintheselectedperiod. problems:(1)MDTservicenot
flexible.Improveservice
deliverytobemorepatient
friendly(2)Patientfollowupis
notsatisfactory.Should
improvefollowupofirregular
patientswhereverpossible(3)
patientisnotwellinformedof
importanceofcontinuingMDT.
Conductproperpatient
Sourceof Frequency
Data ofReporting
educationandcounseling(see
GuideforHealthProfessionals
toEliminateLeprosyasaPublic
HealthProblem)and(4)MDT
wasnotalwaysavailable.Keep
sufficientMDTstockand
improvestockmanagement.

Importantforassessingthe
qualityofpatientmanagement
aswellasprogram
performance

3.11 M A L A R I A
____________________________________________________________________________________________________________________________________________________________
Sourceof Frequency
Data ofReporting
1.Morbidityrateof Numberofconfirmedmalariacasesovertotal Numerator:No.of 15casesper Malaria Annual
ConfirmedMalaria(per populationx100,000disaggregatedbysexand confirmedmalariacases 100,000 Registry
100,000pop) age(>5and<5yearsofage) populationin
Denominator: stablerisk
Typesoftransmission(define): TotalPopulationx provinces
Stable 100,000
Unstable 2.6casesper
Sporadic 100,000in
unstableand
sporadicrisk
provinces

2.AnnualParasite Numberofconfirmedmalariacasesover Numerator:No.of <0.1/1,000 Malaria Annual Toknowwhichprovincesare
Incidence populationatriskx1,000disaggregatedbysex confirmedmalariacases Registry atpreeliminationphase.
andage

Populationatriskreferstothepopulationof Denominator:Atrisk
endemicareaswithahighriskofMalariacases. Populationx1,000

3.Laboratory Laboratoryconfirmedmalariacases denote,for Numerator:TotalNo. of Malaria Quarterly Inmanycountriestheonly
confirmed areasperforminglaboratoryconfirmationof ConfirmedMalariaCases Registry datapresentlyreported
malariacases malariadiagnosis,allpatientswithsignsand/or routinely
symptomsofmalariaandlaboratoryconfirmed Denominator:No.of arethenumberofmalaria
diagnosiswhoreceivedantimalarialtreatment. Malaria cases(severeand
Disaggregatedby: Laboratorydiagnosisconsistsofeitherslide casesseen uncomplicated),themajority
age microscopyorarapiddiagnostictest. ofwhicharebasedon
sex presumptivediagnosisrather
pregnancy thanparasitologic
species confirmation.Whilethese
dataarelimitedand
frequentlyrepresentonlya
smallproportionofmalaria
cases.Iftherearenomajor
changesinthereporting
Sourceof Frequency
Data ofReporting
system,anunderstandingof
theselimitationswillallowfor
useofthedatatogenerate
estimatesoftheoverall
burdenofdiseaseaffecting
communitiesandfortracking
trendsovertime.
4.Laboratory Laboratoryconfirmedmalariacaseseitherby Numerator:No.of Malaria Quarterly
confirmed slideorRDT confirmed Registry
malariacases Malariacasesby
bymethod slide/RDT

disaggregatedby: Denominator:Total
ConfirmedMalariacases
Slidemicroscopy
Rapid
Diagnostic
Test(RDT)
5.Proportionof NumberofPopulationatrisk(perbrgy)givenLLIN Numerator:Numberof 1LLINper2 Malaria Annual

PopulationgivenLLIN personslivinginatriskarea persons Registry
givenLLIN

Denominator:Populationat
risk

6.MalariaMortality Totalnumberofmalariadeathsperyearamong Numerator:No.ofMalaria 0.05deathsor Malaria Annual
Rate targetgroupdividedbymidyearpopulationof Deaths lessper100,000 Registry
thesametargetgroupdisaggregatedbysex. pop.MTDP
Denominator:Total (MediumTerm
Populationx100,000 Development
Plan)stable

0.04deathorless
per100,000pop
Sourceof Frequency
Data ofReporting
inunstableand
sporadic

7.MalariaCase NumberofMalariadeathsovertotalnumberof Numerator:No.ofMalaria Malaria Monthly Determineseverityofdisease
FatalityRatio malariacasesdisaggregatedbysex. Deaths Registry (BHSto
RHU)
Denominator:TotalMalaria Quarterly
Cases (RHUto
nexthigher
level)
3.12 SCHISTOSOMIASIS
____________________________________________________________________________________________________________________________________________________________
Frequency
Indicator Definition Formula Target SourceofData UseandLimitation
ofReporting
1.Prevalenceof Prevalenceofinfectiongivesthenumberof Numerator:No.of 50%reductionin Schistosomiasis Annual Todeterminethe
infection infectedpeopleinthepopulationper100,000 individuals 28endemic Registry status/magnitudeof
population PositiveSchistosomiasis provinces schistosomiasisproblem
Toevaluateiftherateofold
Denominator:No.examined andnewinfectionsare
X100,000 decreasingorincreasing
2.Proportionof Canbeexpressedthroughmeanepg. Numerator:No.of Schistosomiasis Annual Toquantifytheindividuals
intensityof No.ofepg=Numberofovax24 low/medium/high Registry sufferingofsevere
infection infected consequences
Theintensityofinfectiongivesinformationonthe Todecideonappropriate
severity(wormburden)ofaninfection. Denominator:No.ofcases interventionmeasures
Examined Tomonitortheresultsand
impactofprogram(%fallin
arithmeticorgeometricmean
epgpergram(epg)counts)
3.Proportionof CRASSgivestheinformationinthenumberof Numerator:No.ofpersons Schistosomiasis Annual
Schistosomiasis personsinfectedbasedontheclinicalsignsand withS/S Registry
withclinical symptomswithorwithouthepatomegaly.
signsand Denominator:TotalNo.of
symptoms Sjcasedefinition=1majorand2minorS/Swith personsinthe
orwithouthepatomegaly area/school
ofintervention
4.Proportionof Treatmentofcasesistheadministrationof Numerator:No.ofcases Schistosomiasis Annual Todetermineifallcases
schistosomiasis Praziquantel,600mggivenjustonedayin23 treated Registry foundweretreated
cases divideddosesat4060mg/kg Toaddressethicalissuesof
treated Denominator:TotalNo.of nontreatment
PositiveCases Toevaluatedrugutilization
andconsumption

5.Proportionof PercentageofcomplicatedSchistosomiasiscases Numerator:No.of Schistosomiasis Annual Referredcasestohospitalsare
complicated referredtohospitalfacility. complicatedcasesreferred Registry complicatedcaseswithhigh
Schistosomiasis tohospitalfacility indexofsuspicionwhichthe
casesreferred primaryhealthfacilitiescannot
tohospital Denominator:TotalNo.of manage,ex.(1)Neurologic
Frequency
ofReporting
facility Schistosomiasis cases(2)Spinal
casesdetected (3)Cardiovascular(cor
pulmonate)(4)Hepaticor
renalcomplications(5)Pipe
Systemfibrosis(6)
Hypertensive
3.13 TUBERCULOSIS
_____________________________________________________________________________________________________________________________________________________________
Frequency
ofReporting
1.NumberofTB ThisreferstoallTBSymptomaticswhounderwent NumberofTBSymptomatics NTPLaboratory Quarterly Toassessthecasefinding
symptomatics DSSM. whounderwentDSSM Register (RHUto activitiesofaDOTSfacility.
whounderwent next Thiswillalsobeusedto
DirectSputum Definitionofterms: higher estimatesforthelogistics
Smear TBSymptomaticsrefertoapatientwithcough level) neededinthelaboratory
Microscopy oftwoweeksormorewithorwithoutthe activitiesoftheDOTSfacility.
(DSSM) followingsignsandsymptoms:fever,chestor
backpains,hemoptysisorbloodstreakedsputum,
significantweightlossorothersymptomssuchas
sweating,fatigue,bodymalaiseandshortnessof
breath.

2.Numberof ThisreferstoTBsymptomaticswithsmear Numberofsmearpositive NTPLaboratory Quarterly Todeterminethepositivity
smearpositive positiveresultsintheNTPLaboratoryRegistry. discovered/identified Register ratewhichmeasuresthe
discovered/ qualityofscreeningofTB
identified Smearpositivepatientsarethosepatientswithat Symptomaticsandmicroscopy
least2sputumsmearspositiveforAFB. workinaDOTSfacility.

3.Numberofnew Thisreferstothenumberofnewsmearpositive Numberofnewsmear TBCase Quarterly Toassess theCaseNotification
smearpositive casesgiventreatmentandregisteredinaDOTS positivecasesinitiated Registry RateandCaseDetectionRate
casesinitiated facility. treatment ofnewsmearpositivecasesin
treatmentand anarea
registered TBpatientswithpositiveDSSMresultthathave
nottakenantiTBdrugsbeforeoriftheyhave
takenantiTBdrugsitisforlessthan1month.

tocomputeCDRfornewsmearpositives:

CDR=newsmearpositives/{totalpopulationx
0.00131(IncidenceRatefornewsmearpositive)}x
100
Frequency
ofReporting
4.TBCase SummationofallformsofTBpertainingtonew Numerator: Numberofall 85%(NOH2016) Quarterly
DetectionRate(All smearpositive,newsmearnegative,relapseand formsofTBCasesidentified reports(All
formsofTB) extrapulmonaryTB formsreferto
Denominator:estimated newsmear
TocomputeforCDRallforms: numberofallformsofTB positive,new
casesfortheyear smearnegative,
CDRallforms=totalnumberofallformsofTB/ relapseand
{totalpopulationx0.00275(estimatedTBAll Multiplier:X100 extrapulmonary
Forms)}x100 TB)

5.Numberofall ThisreferstothenumberofallformsofTBcases NumberofNewSmear TBCase Quarterly ToassesstheCNRandCDRof
formsofTB (newsmearpositive,newsmearnegative,relapse, positivecasesinitiated Registry (RHUto allformsofTBinanarea
casesinitiated extrapulmonaryTB)regardlessofagegiven treatmentandregistered next
treatmentand treatmentwhoareregisteredinTBCaseRegistry +NumberofsmearNegative higher
registered oftheDOTSfacility. Casesinitiatedtreatment level)
andregistered
AllformsofTBincludetheff: +Numberofrelapsecases
Newsmearpositive initiatedtreatmentand
Newsmearnegative registered
Relapse +Numberofextra
ExtrapulmonaryTB pulmonarycasesinitiated
treatmentandregistered

5.Numberofnew Thisreferstothenumberofnewsmearpositive Numberofnewsmear TBCase Quarterly ToassessthequalityofDOTS
smearpositive caseswhohavecompletedtreatmentandis positivecasesatstartof Registry servicesprovided.
casescureda smearnegativeinthelastmonthoftreatment treatmentwhohave
yearago andonatleastonepreviousoccasioninthe completedtreatmentand
continuationphase. smearnegativeinthelast
monthoftreatmentandon
TocomputeforNewSmearPositiveCureRate: atleast1previousoccasion
inthecontinuationphase
NewSmearPositiveCR=newsmearpositivecases
whogotcured/newsmearpositivecasesdetected
forthatquarter

6.Numberof Thisreferstothenumberofsmearpositivere Numberofsmearpositive TBCase Quarterly Toassessthetrendofre
Frequency
ofReporting
smearpositive treatmentcasesgiventreatmentandregisteredin retreatmentcasesinitiated Registry treatmentcasesfortheyare
retreatment aDOTSfacility. treatment alreadysuspectsfordrug
casesinitiated resistance.
treatmentand Retreatmentcasesrefersto:
registered Relapse,
ReturnafterDefault,
TreatmentFailure,and
OthertypeofTBcasesdoesnotfallin
anyofthementionedabovebutis
positive.

7.Numberof Thisreferstothenumberofsmearpositivere Numberofsmearpositive TBCase Quarterly ToassessthequalityofDOTS
smearpositive treatmentcases: retreatmentcaseswhogot Registry servicesprovidedandto
retreatment cured determineifDOTisbeing
caseswhogot a. Relapsecasescuredarethosewhohave done.
cured completedtreatmentandaresmear
negativeinthelastmonthoftreatment
andonatleastonepreviousoccasionin
thecontinuationphase.

b. ReturnafterDefaultcuredarethose
whohavecompletedtreatmentandis
smearnegativeinthelastmonthof
treatmentandonatleastoneprevious
occasioninthecontinuationphase.

c. TreatmentFailurecuredarethosewho
havecompletedtreatmentandissmear
negativeinthelastmonthoftreatment
andonatleastonepreviousoccasionin
thecontinuationphase.

3.14 MORBIDITY RATES

_____________________________________________________________________________________________________________________________________________________________
Sourceof Frequency
Data ofReporting
1.Toptenleading
causeofmorbidity
2.Morbidityrateof NOTE: Numerator:No.ofnotifiable

Notifiable Notifiablediseasesinclude:both diseasecasesamongthe
diseasesamongthe communicable&noncommunicable elderly
elderly(per100,000 diseases - 6064yrsold
pop)bygender& Canwestartthecutoffoftheageof - 6569yrsold
agegroup(6064 elderlypersonsto60yrsoldinsteadof65 - 70yrs&above
yrs;6569yrs&70 yrsoldtoharmonizewiththedefinitionin
yrs&above) RepublicAct9994(ExpandedSenior Denominator:Total
CitizensActof2010).Anelderlyorsenior population(agegroup:6064
citizenofthePhilippinesatleastsixty(60) yrs;6569yrs&70yrs&
yearsold. above)
Fortheagegroupingsamongtheelderly,
canwefollowthedisaggregationusedin Multiplier:X100,000
thePhil.HealthStatistics:
- 6064yrsold
- 6569yrsold
- 70yrsold&above
3.Influenza NOTE: Numerator:No.ofinfluenza
MortalityRate Cutofftheelderly&agegroupings deathsamongtheelderly
amongtheelderly sameasabove - 6064yrsold
(per100,000pop) - 6569yrsold
bygender&age - 70yrs&above
group(6064yrs;
6569yrs&70yrs& Denominator:Total
above) population(agegroup:6064
yrs;6569yrs&70yrs&
above)

Multiplier:X100,000

4.Pneumonia Pneumoniadeathsamongelderly Numerator:No.of
MortalityRate pneumoniadeathsamong
Sourceof Frequency
Data ofReporting
amongtheelderly NOTE: theelderly
(per100,000pop) Cutofftheelderly&agegroupings - 6064yrsold
bygender&age sameasabove - 6569yrsold
group(6064yrs; (?)laboratoryconfirmed - 70yrs&above
6569yrs&70yrs&
above) Denominator:Total
population(agegroup:6064
yrs;6569yrs&70yrs&
above)

Multiplier:X100,000

5.Prevalenceof Proportionofthepopulation>25y/oatriskfor Numerator:>25y/oatrisk Stilltobe Operations Monthly
>25y/oatriskfor CVDeventin10yrs forCVDevent(bylevelof identified Manualon
CVDeventin10 risk)in10yrs the
years Philippine
Disaggregatedby Denominator:total Packageof
levelofrisk population>25y/oX100 Essential
Level NCD
<10%risk interventions
<20%risk (PhilPen)on
<30%risk the
<40%risk Integrated
>=40%risk Management
of
Hypertension
andDiabetes
forPrimary
HealthCare
Facilities
(Annex4.
Patients
Record)
6. Numberofcases Allindividualswithurethraldischargethatare Numberofindividualswith SSESS Monthly
withurethral diagnosedbyinspection urethraldischargethatare Manualof
discharge diagnosedbyinspection Operations
(Syndrome Disaggregatebysex,andagegroup(<15yo,15to (Appendix
Sourceof Frequency
Data ofReporting
Reporting) 17yo,18to24yo,>24yo) A.1ICR);
FHSISITR
7. Numberofcases Allindividualswithgenitalulcersthatare Numberofindividualswith SSESS Monthly
withgenital diagnosedbyinspection genitalulcersthatare Manualof
ulcer(Syndrome diagnosedbyinspection Operations
Reporting) Disaggregatebysex,andagegroup(<15yo,15to (Appendix
17yo,18to24yo,>24yo) A.1ICR);
FHSISITR
8. Percentageof Allfemaleswhohaveacervicalsmearandare Numerator:Numberof SSESS Monthly
gonorrheacases foundtohavegramnegativeintracellular smearsthatarefoundto Manualof
amongsmears diploccoci havegramnegative Operations
done(Etiologic intracellulardiplococci (Appendix
Reporting) Allmaleswhohaveaurethraloranalsmearand A.1ICR);
arefoundtohavegramnegativeintracellular Denominator:Totalnumber FHSISITR
diplococci ofsmearsdone

Disaggregatebysex,andagegroup(<15yo,15to
17yo,18to24yo,>24yo)
9. Percentageof Allindividualswhoarepositiveforsyphilis Numerator:Numberoftests SSESS Monthly
syphiliscases thatarepositivefor Manualof
amongRPR Disaggregatebysex,andagegroup(<15yo,15to TreponemaPallidum Operations
screeningdone 17yo,18to24yo,>24yo) HemaglutinationAssayor (Appendix
(Etiologic TPHA A.1ICR);
Reporting) FHSISITR
Denominator:Totalnumber
ofRPRscreeningtestsdone
___________________
ANNEXES
Republic of the Philippines
Departmentof Health
NATIONAL EPIDEMIOLOGY CENTER
Bldg. # g,SanLazaro Compound,Rizal Avenue,Sta.Cruz, 1003Manila
Telefax:rc32\743-8301loc.1900 Trunkline:743-8301 local1900-1907Directline:743'1937
URL : http:iiwww.doh. gov.ph ; E-mail : nec@doh.gov.ph
FOR : ALL CHD RegionalDirectors
ATTENTION: ALL FHSIS Regional/ProvinciaVCity Coordinators
FROM nNNqtWt*{G, MD,PHSAE, cESovI

FPSMTD,
DirectorIV U
/
SUBJECT FHSIS Family Planning Calculation Correction on Current

Users
DATE September312010
The following is an updateon the Family PlanningCurrentUsersFormula and

Calculation.
GUIDE IN FILLING-UP THE FORMS:
1. FOR MONTHLY FORM for FAMILY PLAI\NING
Current UsersBeg. Month (ex. February)

Formula:Just carry over the CU data of previous month (January)
New Acceptors(ex. February)

Formula: Count Total No. of New Acceptorsfor the month of Februaryin the
TCl/Summary Tables
o Other Acceptors(ex. February)

Formula: Count Total No. of OtherAcceptorsfor the Month of Februaryin
the TCl/Summarv Tables
Cc: NCDPC (Family PlanningProgram)
180
Current Users End. Month (ex. February)
Calculation:
Current users from the previous month (Jan)
+ New Acceptors (previous month) (Jan)
+ Other Acceptor (current month) (Feb)
- Drop-outs (current month) (Feb)
= Current User of ending month (Feb)
Example: Calculation for the Month of January to March
Given: New Acceptors for the month of December = 8
Month CU New Other Dropouts CU

Beg Mo. Acceptors Acceptors End Mon
January 15 6 7 1 29 = (15 + 8
+ 7 1)
February 29 3 4 2 37= (29 + 6
+ 4 2)
March 37 8 9 5 44 = (37 + 3
+ 9 5)
2. FOR QUARTERLY FORM (ex. for First Quarter)
Current Users Beg. Quarter (ex. First Quarter)

Formula: Just carry over the CU data at the start of the First Quarter
(January)
New Acceptors (ex. First Quarter)

Formula: Count Total No. of New Acceptors for the First Quarter (January to
March) from the TCL/Summary Tables
Other Acceptors (ex. February)

Formula: Count Total No. of Other Acceptors for the First Quarter (January to
March) in the TCL/Summary Tables
Dropouts (ex. February)

Formula: Count Total No. Of Dropouts for the First Quarter (January to
March) in the TCL/Summary Tables
Current Users End. Quarter (ex. First Quarter)

Formula: carry over the CU end of the month data from the last month of the
Quarter (March) for First Quarter
Cc: NCDPC (Family Planning Program)
181
January 15 6 7 1 29
February 29 add 3 add 4 add 2 37
March 37 8 9 5 44
First Quarter 15 17 21 8 44

April 44 2 6 5 53
May 53 add 1 add
3 add
4 54
June 54 3 7 9 53
Second Quarter 44 6 16 18 53
Cc: NCDPC (Family Planning Program)
182
Annex2.IndividualTreatmentRecords
2.1ManagementoftheSickYoungInfantAge1Weekupto2Months
2.2ManagementoftheSickChildAge2Monthsupto5Years
2.3ChildrenUnderFiveYearsofAgewithHealthProblemsotherthanIMCI
Classification/OtherChildren/Adults
2.4MaternalClientRecordforPrenatalCare
2.5MaternalClientRecordforPostpartumandNeonatalCare
2.6FamilyPlanningServiceRecord
2.7DentalHealthProgramForm1
2.8TBProgramIndividualTreatmentCard
2.9ITRforMalariaPreventionandControlProgram
2.10ITRfortheLeprosyPreventionandControlProgram
2.11ITRfortheSchistosomiasisPreventionandControlProgram
2.12ITRfortheFilariasisPreventionandControlProgram

Annex 2.1 Department of Health
Integrated Management of Childhood Illness Strategy
INDIVIDUAL TREATMENT RECORD (ITR) Family Serial No. __________

MANAGEMENT OF THE SICK YOUNG INFANT AGE 1 WEEK UP TO 2 MONTHS
Date: ____________
Childs Name: _________________________ Age: ____ Sex: ____ Weight: _____ kg Temperature: ______C
Address: ________________________________________ Mothers Name: _______________________________
ASK: What are the childs problems? _______________________ Initial visit? __________ Follow-up visit? ________
ASSESS (Circle all signs present) CLASSIFY
CHECK FOR POSSIBLE BACTERIAL INFECTION
Has the infant had convulsions? Count the breaths in one minute. ____ breaths per minute.
Repeat if elevated _____. Fast breathing?
Look for severe chest indrawing.
Look for nasal flaring.
Look and listen for grunting.
Look and feel for bulging fontanelle.
Look for pus draining from the ear.
Look at the umbilicus. Is it red or draining pus? Does the
redness extend to the skin?
Fever (temperature 37.5C or above or feels hot) or low body
temperature (below 35.5C or feels cool)
Look for skin pustules. Are there many or severe pustule?
See if the young infant is abnormally sleepy or difficult to
awaken.
Look at young infants movements. Less than normal?
DOES THE YOUNG INFANT HAVE DIARRHEA? Yes ___ NO ___
For how long? ___ Days Look at the young infants general condition. Is the infant:
Is there blood in the stools? Abnormally sleepy or difficult to awaken
Restless or irritable?
Look for sunken eyes.
Pinch the skin of the abdomen. Does it go back:
Very slowly (longer than 2 seconds)?
Slowly?
THEN CHECK FOR FEEDING PROBLEM OR LOW WEIGHT
Is there any difficulty feeding? Yes __ No__ Determine weight for age. Low ___ Not Low ___
Is the infant breastfed? Yes __ No __
If Yes, how many times in 24 hours? __ times
Does the infant usually receive any other foods or
drinks? Yes ___ No ___
If Yes, how often?
What do you use to feed the child?
If the infant has any difficulty feeding, is feeding less than 8 times in 24 hours, is taking any other food or drinks, or
is low weight for age AND has no indications to refer urgently to hospital:
ASSESS BREASTFEEDING:
Has the infant breastfed in the previous hour? If infant has not fed in the previous hour, ask the mother to put her
infant to the breast. Observe the breastfeed for 4 minutes.
Is the infant able to attach? To check attachment, look for:
- Chin touching breast Yes __ No __
- Mouth wide open Yes __ No __
- Lowe lip turned outward Yes __ No __
- More areola above than below the mouth Yes __ No __
no attachment at all not well attached good attachment
Is the infant suckling effectively (that is, slow deep sucks,

sometimes pausing)?
not suckling at all not suckling effectively suckling effectively
Look for ulcers or white patches in the mouth (thrush)
CHECK THE YOUNG INFANTS IMMUNIZATION STATUS Circle immunizations needed today. Return for next
immunization on:
____ _____ _____ _____ ____________
BCG DPT1 OPV1 HEP B1 (Date)
ASSESS OTHER PROBLEMS:

TREAT
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
Return for follow-up in: ___________________________________
Give any immunization needed today: _______________________
Feeding Advice: _________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
_______________________________ ____________________
Name of Health Worker Signature
Annex 2.2 Republic of the Philippines
Department of Health-ARMM
Integrated Management of Childhood Illness Strategy
INDIVIDUAL TREATMENT RECORD (ITR) Family Serial No. __________
MANAGEMENT OF THE SICK CHILD AGE 2 MONTHS UP TO 5 YEARS
Date: ____________
Childs Name: ____________________________ Age: _____ Sex: ______ Weight: _______ kg Temperature:
_________C
Address: ____________________________________________ Mothers Name: ______________________________________
ASK: What are the childs problems? ___________________________ Initial visit? ______________ Follow-up visit? _________
ASSESS (Circle all signs present) CLASSIFY
CHECK FOR GENERAL DANGER SIGNS
NOT ABLE TO DRINK OR BREASTFEED
VOMITS EVERYTHING ABNORMALLY SLEEPY OR DIFFICULT TO AWAKEN YES ___ NO ___
CONVULSIONS
DOES THE CHILD HAVE COUGH OR DIFFICULT BREATHING? Yes ___ No ___
For how long? ___ days Count the breaths in one minute.
____ breaths per minute. Fast breathing?
Look for chest indrawing.
Look and listen for stridor.
DOES THE CHILD HAVE DIARRHEA Yes ___ No ___
For how long? ___ days Look at the childs general condition.
Is there blood in the stools? Abnormally sleepy or difficult to awaken?
Restless or irritable?
Look for sunken eyes.
Offer the child fluid. Is the child:
Not able to drink or drinking poorly?
Drinking eagerly, thirsty?
Pinch the skin of the abdomen. Does it go back:
Very slowly (longer than 2 seconds)?
Slowly?
DOES THE CHILD HAVE FEVER? (by history/feels hot/temperature 37.5C or above) Yes ___ No ___
Decide Malaria Risk
Does the child live in a malaria area? Look or feel for stiff neck.
Has the child visited a malaria area in the past 4 Look for runny nose.
weeks?
If malaria risk, obtain a blood smear.
+ Pf Pv - Not done Look for signs of MEASLES.
For how long has the child had fever? __ days. Generalized rash and
If more than 7 days, has fever been present every One of these: cough, runny nose or red eyes.
day?
Has the child had measles within the last 3 months?
If the child has measles now or Look for mouth ulcers.
within the last 3 months If yes, are they deep and extensive?
Look for pus draining from the eye.
Look for clouding of the cornea.
Dengue Risk:
Then ask:
Has the child had any bleeding from the nose or gums Look for bleeding from nose or gums
or in the vomitus or stools? Look for skin petechiae.
Has the child had black vomitus or black stool? Feel for cold and clammy extremities.
Has the child had persistent abdominal pain? Check capillary refill. _____ seconds.
Has the child been vomiting? Perform tourniquet test if child is 6 months or older AND
has no other signs AND has fever for more than 3
days. (+) (-) (not done)
DOES THE CHILD HAVE AN EAR PROBLEM? Yes ___ No ___
Is there ear pain? Look for pus draining from the ear
Is there ear discharge? Feel for tender swelling behind the ear.
If Yes, for how long? ______ days
THEN CHECK FOR MALNUTRITION AND Look for visible severe wasting.
ANEMIA Look for edema of both feet.
Look for palmar pallor.
Severe palmar pallor? Some palmar pallor?
Determine weight for age.
Very low?
CHECK THE CHILDS IMMUNIZATION STATUS Circle immunizations needed today.
____ ____ _____ ______ Return for next
BCG DPT1 OPV1 HEP B1 immunization on:
____ _____ ______ ______
DPT2 OPV2 HEP B2 AMV 1 ___________
____ _____ ______ _______ (Date)
DPT3 OPV3 HEP B3 AMV 2
CHECK THE VITAMIN A SUPPLEMENTATION STATUS for children 6 months or older Vitamin A needed
Is the child six months of age or older? Yes __ No ___ today
Has the child received Vitamin A in the past six months? Yes __ No ___ Yes ___ No ___
ASSESS CHILDS FEEDING If child has ANEMIA OR VERY LOW WEIGHT or is less than 2 years old. Feeding
Do you breastfeed your child? Yes ___ No ____ Problems:
If Yes, how many times in 24 hours? __ times. Do you breastfeed during the night? Yes ___ No ___
Does the child take any other food or fluids? Yes __ No ___
If Yes, what food or fluids? ________________________________________________________________
How many times per day? __ times. What do you use to feed the child? ____________________________
If very low weight for age: how large are servings? _____________________________________________
Does the child receive his/her own serving? ____ Who feeds the child and how? _____________________
During the illness, has the childs feeding changed? Yes ___ No ___
If Yes, how?
ASSESS OTHER PROBLEMS:
TREAT
Remember to refer any child who has a danger

sign and no other severe classification.
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
Return for follow-up in: ___________________________________
Advise mother when to return immediately:
Give any immunizations needed today: _______________________
Give vitamin A if needed today: _____________________________
Feeding Advice: _________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
_______________________________ ____________________
Name of Health Worker Signature
Department of Health-ARMM
Annex 2.3
INDIVIDUAL TREATMENT RECORD (ITR)
Children and Other Adults
A. Patients Personal Profile Family Serial No. __________________
Patients Name: ______________________________________________________ Sex: _______

Family Name First Name Middle Name
Birthdate:______________________________________ Civil Status:___________
Occupation:________________________________ Agency/Company:_______________________
Parent/Guardian/Contact Person:______________________________________________________
Address: __________________________________________________________________________
Contact Number: ____________ Health Insurance Membership: ___________________________
B. Patients Case Summary
Date of Visit:____________________ Age (in months if under five years of

age):______
I. Subjective Complaints:
Chief Complaint: ___________________________________________________________
Present Illness: ____________________________________________________________

__________________________________________________________________________
__________________________________________________________________________
Past History:_______________________________________________________________
__________________________________________________________________________
II. Objective findings:
Vital signs: BP if needed:______ Heart Rate: _______ Respiratory Rate:_______

Temperature: _______ Weight:__________ Height:__________
Physical Examination:_______________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
III. Assessment/Classification:
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
IV. Plan of Management: (Treat, Refer and Health Educate)

__________________________________________________________________________
__________________________________________________________________________
_____________________________________
Name and Signature of Service Provider
Annex 2.4
Republic of the Philippines MNC Form I SIDE A
MATERNAL CLIENT RECORD for Prenatal Care Family Serial NO.
MEDICAL HISTORY PHYSICAL EXAMINATION
NO. OF LIVING CHILDREN: _____

AVERAGE MONTHLY Family INCOME ______________
NAME OF SPOUSE: _____________________ __________________ ____
NAME OF CLIENT: _____________________ __________________ ____

REVIEW OF SYSTEMS VITAL SIGNS
HEENT Blood Pressure: ___________ mm Hg
Epilepsy/Convulsion/Seizure Weight: ___________ kg
Severe headache/dizziness Pulse Rate: ____________/ min
Visual disturbance/blurring of vision CONJUNCTIVA
Yellowish conjunctiva Pale Yellowish
Enlarged thyroid NECK
CHEST/HEART Enlarged thyroid Enlarged lymph nodes
Severe chest pain BREAST
Shortness of breath and easy fatigability Mass
Breast/axillary masses Right Left Breast
Nipple discharges (specify if blood or pus)
LAST NAME
Last NAME
Breast
ABDOMEN
Mass in the abdomen
History of gallbladder disease
History of liver disease
BIRTH PLAN: Hospital RHU LIC Home IF AT HOME, WHO IS THE Birth Attendant: SBA Non-SBA
GENITAL
Vaginal discharge Nipple discharge
Intermenstrual bleeding Skin orange peel or dimpling
Postcoital bleeding Enlarged axillary lymph nodes
Mass in the uterus THORAX
GIVEN NAME
GIVEN NAME
EXTREMITIES Abnormal heart sounds/cardiac rate
Severe varicosities Abnormal breath sounds/respiratory rate
Swelling or severe pain in the legs not related to ABDOMEN
injuries Enlarged liver Tenderness
SKIN Mass Scar
Yellowish skin
FAMILY HISTORY
M.I.
M.I.
CVA (strokes) VAGINAL EXAMINATION:
Hypertension Bleeding Discharges Cyst/mass
DATE OF BIRTH (mo/day/year)

Scars Warts Laceration
____/____/________
Asthma
____/____/________ _______________
Heart disease Others (Specify)________________________
Diabetes
PAST HEALTH HISTORY EXTREMITIES
Allergies Edema
Drug intake (anti-tuberculosis, anti-diabetic, Varicosities
anticonvulsant) Pain on forced dorsiflexion
Bleeding tendencies (nose, gums, etc.)
Anemia TT Status: _______________________
Diabetes ______
AGE :
HIGHEST EDUC
Itching or sores in or around vagina

Pain or burning sensation on urination
SOCIAL HISTORY
_______________ ______________
Smoking Sticks per day ___________

HIGHESST EDUC
Alcoholic beverage Amt. Per day ________

Obesity
History of domestic violence or VAW
Unpleasant relationship with partner
Treated for STIs in the past
OBSTERICAL HISTORY
Number of pregnancies:
______ Full Term ______ Premature IMPRESSION/DIAGNOSIS
OCCUPATION
______ Abortions ______ Living Children

History of Ectopic pregnancy
Hydatidiform mole (within the last 12 months)
History of Previous Deliveries
_____________ ______
Date of last delivery ___/__/_____

MUNICIPALIY
____________ ____
Type of last delivery _______________

NO. STREET
Birth Attendant in last delivery __________

Menstrual History
Last menstrual period _______________
PR
Past menstrual period _______________
Duration of Menstrual bleeding ________
Character of Menstrual bleeding (no. of pads)
_________________
FAMILY PLANNING HISTORY
Previously Used Method: ______________________
Reminder: Kindly refer to PHYSICIAN for any checked () findings for further evaluation.
MATERNAL CLIENT RECORD for Prenatal Care SIDE B
DATE MCN SERVICES GIVEN

COMPLAINTS/COMPLICA Tetanus Toxoid
TIONS Anti-Helminthic
MEDICAL OBSERVATION Anti-Malaria NAME OF NEXT
PE Findings including pelvic Iron/Folate PROVIDER Follow-Up
examination FP Counseling AND Schedule
Counseling for Danger Signs SIGNATURE
Laboratory
OTHER IMPORTANT Referral Made
COMMENTS IF ANY
Abdominal Examination Findings
1st Trimester 2nd Trimester 3rd Trimester

1st mo 2nd mo 3rd mo 4th mo 5th mo 6th mo 7th mo 8th mo 9th mo REMARKS
Date
Fundic Height (cm)
Fetal Heart Tones
AOG
Leopolds
L1
L2
L3
L4
Uterine Activity
USE ADDITIONAL SHEETS AS NECESSARY

Adapted from the DOH Family Planning Service Record; updated 02/09/06.
MATERNAL CLIENT RECORD for Prenatal Care Family Serial NO.
Name of Client: ______________________
BIRTH AND EMERGENCY PLAN

I know that any complication can develop at any time in the course of this pregnancy, childbirth and after birth. I know
that the best place to deliver my baby is in a health facility.
I will be attended at delivery by _________________________________________________________________________

(Name of Doctor/Nurse/Midwife or others. If others, pls. specify)
I plan to deliver at _____________________________________________________________________________________
(Name and location of hospital/health center/clinic or others. If others, pls. specify)
This is a Philhealth accredited facility Yes No Distance from Residence __________________________
The estimated cost of the maternity package in this facility is PhP _____________________ (Inclusive of newborn care)
The mode of payment is _____________________________.
The available transport is ____________________________.
I have contacted ______________________, residing at _______________________________________ and with contact

(Name of Companion) (Address)
number at __________________________, to bring me to the hospital/maternity clinic/health center.
(Landline or Cellphone)
I will be accompanied by _____________________________________, who is my ______________________, residing at
(Name) (Relationship to patient)
___________________________________________________, and with contact number ___________________________.
(Address) (Landline or Cellphone)
_________________________________________, my ____________________, will take care of my children/home while
(Name of care taker) (Relationship to patient)
I am in the health facility.
My blood type is: __________________
In case of a need for blood transfusion, my possible donors are:

_____________________________________ ______________________________________________________________
(Name) (Address)
_____________________________________ ______________________________________________________________
(Name) (Address)
In case of complications, I should be referred right away to:

Contact Person: ___________________________________________________________________
Address: __________________________________________________________________________
Tel. No.: __________________________________________________________________________
The nearest maternal and newborn health facility to my residence are:
Maternal/Hospital: __________________________________ ___________________________________________

(Name of Hospital) (Address)
Newborn Hospital: ___________________________________ ___________________________________________
(Name of Hospital) (Address)
Conforme:
___________________________ __________
Signature Date
Annex 2.5 Department of Health
MNC Form 2 SIDE A
MATERNAL CLIENT RECORD for Postpartum and NeonatalCare Family Serial NO.
AVERAGE MONTHLY Family INCOME ______________
NAME OF SPOUSE: _____________________ __________________ ____
NAME OF CLIENT: _____________________ __________________ ____

Date of visit: ______________________
Physical Examination
Date of Delivery: ______________________ Attendant: Doctor
Outcome: Livebirths Still birth abortion Nurse
Sex: Male Female Midwife
Type of Delivery: NSD CS Others TBA/Hilot
Place of Delivery: Home Others
Health Facility AMTSL Steps:
LAST NAME
Last NAME
Government Hospital 1. Oxytocin injected w/in 1 minute
Private Hospital of delivery Yes No
Private Clinic/Birthing 2. Controlled cord contraction
Main Health Center done Yes No
BHS/Birthing Home 3. Uterine massage done Yes No
Others: Therefore, AMTSL provided: Yes No
GIVEN NAME
(Check yes if all the 3 steps were done)
GIVEN NAME
ASSESSMENT OF THE POST PARTUM MOTHER NEWBORN ASSESSMENT
Postpartum Visits Postnatal Visits

Danger Signs Danger Signs (Baby)
(Mother) w/in 24 w/in Other w/in 24 w/in Other
hrs 5-10 days visits hrs 3-5days visits
M.I.
M.I.
If breathing is >60/min or
Unconscious <30/min
Vaginal Bleeding Severe chest indrawing

____/____/________
No. of pads per day
____/____/________ _______________ ________________

Grunting
Severe abdominal Convulsions
Pain
Floppy or stiff extremities
Looks very ill Temp.>37.5 or <35.5
Bleeding from umbilical
Severe headache
stump or cut
with visual
Umbilicus draining pus or
disturbance umbilical redness
Severe difficulties of extending to skin
______
AGE :
HIGHEST EDUC
breathing More than 10 skin
pustules or swelling,
Post partum redness, or hardness of
depression skin
_______________ ______________ ____________ ___________

HIGHESST EDUC
Postpartum Visits
PelvicExam Immediate Essential Newborn
w/in 24 w/in 5-10 Other Care (ENC) Yes No
Findings
hrs days visits
1. Immediate & thorough drying
Uterus
OCCUPATION
2. Early skin to skin contact

Contracted
Relaxed 3. Timely cord clamping
Vaginal Bleeding : 4. Early initiation of breast-
feeding w/in 90 minutes
Profuse
Early ENC given (check yes if all 4
OCCUPATION
Moderate
Scanty components were provided)
Vaginal Discharge: Breastfeeding:

Color After 90 minutes but w/in twenty-four (24) hrs
_____________ _______________
MUNICIPALIY
Odor
Vaginal Laceration Postnatal Visits
Other ENC Given
1st Degree
NO. STREET
w/in 24 w/in 3-5 Other

2nd Degree hrs days visits
3rd Degree 1. Vit. K injection
If with laceration, 2. Eye prophylaxis
Sutured? 3. Referred for
Yes or No Newborn Screening
PROVINCE
If CS, bleeding Others

BARANGAY
and/or swelling
from the wound Newborn Screening Done:
Yes Date ______________ No
Date Result ____________
Supplementation: Number Given
No. of tablets given (60mcg
MATERNAL CLIENT RECORD for Postpartum and Neonatal Care SIDE B
DATE MCN SERVICES GIVEN

COMPLAINTS/COMPLICAT Tetanus Toxoid
IONS Vitamin A
MEDICAL OBSERVATION Anti-Malaria NAME OF NEXT
Pertinent PE Findings Iron/Folate PROVIDER Follow-Up
including pelvic examination FP Counseling AND Schedule
Counseling for Danger Signs SIGNATURE
Laboratory
OTHER IMPORTANT Referral Made
COMMENTS IF ANY
Family Serial No.________
Annex 2.6 Republic of the Philippines
FAMILY PLANNING SERVICE RECORD* SIDE A

MEDICAL HISTORY PHYSICAL EXAMINATION
METHOD ACCEPTED: COC Contraceptive patch POP Injectable Condom IUD BTL VSC LAM SDM BBT Billings/Cervical Mucus/Ovulation Method
NAME OF SPOUSE: _________________ ______________ ____ ____/____/________ _________________ _________________ AVERAGE MONTHLY INCOME : ___________
NAME OF CLIENT: _________________ ______________ ____ ____/____/________ _____ ______________ ______________ _________ _________ ___________ ___________
CLIENT NO.: ____
HEENT Blood Pressure: ___ mm Weight: ____ kg/lbs
Epilepsy/Convulsion/Seizure Enlarged thyroid Pulse Rate: _____/ min (N.V. = 70 to 80/min)
Severe headache/dizziness Yellowish
Visual disturbance/ conjunctiva CONJUNCTIVA
blurring of vision Pale Yellowish
NECK
CHEST/HEART
Enlarged thyroid
Severe chest pain
Shortness of breath and easy fatigability Enlarged lymph nodes
TYPE OF ACCEPTOR:
Breast/axillary masses BREAST Right Breast Left Breast
Nipple discharges (specify if blood or pus) Mass
Systolic of 140 & above Nipple discharge
LAST NAME
LAST NAME
Diastolic of 90 & above Skin orange peel or dimpling
Family history of CVA (strokes), hypertension asthma,
Enlarged axillary lymph nodes
rheumatic hearth disease
THORAX
PLAN MORE CHILDREN : Yes No

ABDOMEN Abnormal heart sounds/cardiac rate
Mass in the abdomen Abnormal breath sounds/respiratory rate
History of gallbladder disease ABDOMEN
New to the Program

History of liver disease Enlarged lever Mass
GENITAL Tenderness
GIVEN NAME
EXTREMITIES
GIVEN NAME
Mass in the uterus Intermenstrual bleeding
Vaginal discharge Postcoital bleeding Edema Varicosities
EXTREMITIES PELVIC EXAMINATION

Severe varicosities Others (Please specify) __________________
Swelling or severe pain in the legs not related to injuries PERINEUM
UTERUS
Continuing User
SKIN Scars Position
M.I.
Yellowish skin Warts
M.I.
Mid
HISTORY OF ANY OF THE FOLLOWING Reddish
Anteflexed
Smoking

Laceration
REASON FOR PRACTICING FP: _______________________________________________

Allergies VAGINA Retroflexed
Drug intake (anti-tuberculosis, anti-diabetic, anticonvulsant) Congested
Size
Bleeding tendencies (nose, gums, etc.)
Bartholins cyst Normal
Anemia
PREVIOUSLY USED METHOD: ___________________

Warts Small
Diabetes
Skenes Gland Large
Discharge Mass
OBSTERICAL HISTORY Rectocele Uterine Depth: ___cms.
Number of pregnancies:
______ Full Term ______ Premature
Cystocele (for intended IUD users)
CERVIX
_______ Abortions ______ Living Children
________ Full Term Congested ADNEXA
AGE
Date of last delivery ___/__/_____ Erosion
Mass
Type of last delivery _______________
HIGHEST EDUC
Discharge
Past menstrual period _______________ Tenderness
Polyps/cysts
Last menstrual period _______________ HIGHEST EDUC
Laceration
Duration and character Consistency
Menstrual bleeding ________________ Firm Soft
RISKS FOR VIOLENCE AGAINST WOMEN (VAW)
History of domestic violence or VAW

HISTORY OF ANY OF THE FOLLOWING Unpleasant relationship with partner
OCCUPATION NO. ST BGY MUNI PROV
Hydatidiform mole (within the last 12 months) Partner does not approve of the visit to FP clinic
Ectopic pregnancy
Partner disagrees to use FP
OCCUPATION
STI RISKS Referred to: DSWD WCPU NGOs

DATE/TIME ________________
With history of multiple partners Others (specify: ______________)

For Women:
ACKNOWLEDGEMENT:
Unusual discharge from vagina This is to certify that the Physician/Nurse/ Midwife of the
Itching or sores in or around vagina clinic has fully explained to me the different methods available in
Pain or burning sensation family planning and I freely choose the
Treated for STIs in the past ______________________ method.
For Men: _______________________ ___________
Pain or burning sensation Client Signature Date
Open sores anywhere in genital area
Pus coming from penis
Swollen testicles or penis
Treated for STIs in the past
Reminder: Kindly refer to PHYSICIAN for any checked () findings prior to provision of any method for further evaluation.
FAMILY PLANNING SERVICE RECORD
METHOD REMARKS NAME OF NEXT
TO BE MEDICAL OBSERVATION PROVIDER SERVICE
USED/SUPPLIES COMPLAINTS/COMPLICATIONS AND DATE
GIVEN SERVICE RENDERED/PROCEDURES/ SIGNATURE
DATE INTERVENTIONS DONE (laboratory examination,
SERVICE METHOD/ NO. OF treatment, FP referrals, FP counseling, contraceptive
GIVEN dispensing, etc.)
BRAND UNITS
REASONS FOR STOPPING OR CHANGING
METHOD/BRAND
OTHER IMPORTANT COMMENTS IF ANY
DONT LEAVE ANY BOXES BLANKS NOT FILLED-UP

* Adapted from the DOH Family Planning Service Record; updated 02/09/0
Annex 2.7
SUMMARY OF SERVICES RENDERED
Date Tooth Oral Temp. Perm. Sealant Exo. Consul- Others Remarks Signature
No. Prophy Filling Filling Tation (Specify)
Family Serial No. _______
Dental Health Program
Individual Treatment Record

Name
___________________________________________
__________
Surname First Name
M.I.
Date of Birth ________________________ Age ______ Sex
__________
Place of Birth
___________________________________________
__________
Address
___________________________________________
__________
Occupation
___________________________________________
__________
Parent/Guardian
___________________________________________
__________
Medical History
___________________________________________
__________
___________________________________________
__________
Oral Health Status

A. Check ( / ) if present ( X ) if absent
Date of Oral Examination
Dental Caries
Gingivitis/Periodontal
Disease
Debris
Calculus
Abnormal Growth
Cleft Lip/Palate
Others (supernumerary/
mesiodens, etc)
B. Indicate Number
No. of Perm. Teeth Present
No. of Perm. Sound Teeth
No. of Decayed teeth (D)
No. of Missing Teeth (M)
No. of Filled Teeth (F)
Total DMF Teeth
No. of Temp. Teeth Present
No. of Temp. Sound Teeth
No. of decayed teeth (d)
No. of filled teeth (f)
Total of Teeth
A. Oral Health Condition P Pontic P
Year I Date
Year IV Date
B. Services Monitoring Chart
55 54 53 52 51 61 62 63 64 65
55 54 53 52 51 61 62 63 64 65 Date Sealant/PF/TF/Exo
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27
28
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 55 54 53 52 51 61 62 63 64 65
38
85 84 83 82 81 71 72 73 74 75
85 84 83 82 81 71 72 73 74 75
Year II Date
55 54 53 52 51 61 62 63 64 65
Year V Date 85 84 83 82 81 71 72 73 74 75
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 55 54 53 52 51 61 62 63 64 65 Date Sealant/PF/TF/Exo
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27
28
85 84 83 82 81 71 72 73 74 75
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
38
Year III Date
55 54 53 52 51 61 62 63 64 65 85 84 83 82 81 71 72 73 74 75
Capital letters shall be used for recording the condition of

18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
permanent dentition and small letters for the status of 48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
temporary dentition
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 Permanent Tooth Condition Temporary Legend:

Legend: Sound S - Sealant
D Decayed D PF - Permanent Filling (composite, Am/ART)
85 84 83 82 81 71 72 73 74 75 F Filled F
TF - Temporary Filling
M Missing M
Un Unerupted Un X - Extraction
JC Jacket Crown Jc O - Others
Republic of the Philippines Annex 1 TB
Annex 2.8 Tuberculosis Prevention and Control Program
INDIVIDUAL TREATMENT CARD (ITC) Family Serial No.
________
TB Case Number Date the Card is Opened Region-Province/City Name of DOTS Facility
Month day year

Name of Patient Occupation Age Sex Contact Number
Address: BCG Scar

[ ] Yes [ ] No
[ ] Doubtful
Name/Relationship/Address of Contact Person Contact Number
Source of Patient: History of Anti-TB Drug Intake: [ ] No [ ] Yes No. of Household

[ ] Public [ ] Private Duration: [ ] < 1 mo. [ ] > 1 mo. contacts:
Name of Referring Physician: Specify drugs: ___________________ ( ) < 10 yrs old
When:_________________ Where: __________________Smear Status _______________ ( ) 10 yrs old
Classification of TB: Category (encircle):

[ ] Pulmonary I. 2HRZE/4HR II. 2HRZES/1HRZE/5HRE
[ ] Extra-pulmonary, specify site: ____________________ New Case 1. Relapse
1. Smear (+) 2. Treatment Failure
Type of Patient: 2. Seriously ill 3. Return After Default (RAD)
[ ] New [ ] Return After Default (RAD) 2.1. Smear (-) with extensive 4. Other (smear+/-)
[ ] Relapse [ ] Treatment failure parenchymal lesions as III. (2HRZE/4HR)
[ ] Transfer-in [ ] Other assessed by the TBDC New Case
3. Extra-pulmonary 1. Smear (-) with minimal
parenchymal lesions as
assessed by the TBDC
Sputum Examination Results/Weight Record Treatment started: month____ day____ year__________
Month Due Date Date Result Weight (kg) Treatment Outcome:

Examined
0 [ ] Cured [ ] Failed
Date:__/__/__ Date:__/__/__
2
3 [ ] Treatment Completed [ ] Defaulted
Date:__/__/__ Date:__/__/__
4 Specify:___________________
5 [ ] Died [ ] Transferred out
6 Date:__/__/__ Date:__/__/__
Cause:_______________ Specify: ___________________
>7
Chest X-ray result (If applicable): TBDC findings and recommendations:
_______________________________________________________________ _______________________________________________________________
Name of treatment partner: ________________________________________ Designation of treatment partner:_____________________________
Drug Intake (Intensive phase)
Doses
Cumulative
given for
Month 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 this
Doses
given
month
Drug Intake (Continuation Phase)
Doses
Cumulative
given for
Month 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 this
Doses
given
month
REMARKS: ___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Annex 2.9
Republic of the Philippines Annex 3 Malaria
Malaria Prevention and Control Program
INDIVIDUAL TREATMENT RECORD (ITR) Family Serial No.

Laboratory Result
For the Health Worker Slide Number __________
PLACE PATIENT CONSULTED Microscopy RDT
Hospital RHU BHS Others Pf Pf
BMC Pv Pv
Month Day Year Pm Neg
DATE CONSULTED NMPS
Clinical Diagnosis
NAME OF PATIENT _______________________________________________________________________________________

Last Name First Name M.I.
AGE Year Month (if below 1 yr old)
SEX Male Female
PREGNANT Yes No
WEIGHT ________________ kilo/s
IP Yes, tribe _________________________ No
OCCUPATION (PATIENT)
None Farmer Logger
Fisherman Miner Others ________________________
ADDRESS _______________________________________________________________________________________
Street Brgy. Mun. Prov.
HOUSEHOLD HEAD ______________________________________________________________________________________

CHIEF COMPLAINT ______________________________________________________________________________________
Month Day Year

ONSET OF ILLNESS
MALARIA LABORATORY RESULT:
Name of the BMC/RHU/Hospital Staff __________________________________________________________________________

Name of Microscopist __________________________________________________________________________
Month Day Year
DATE SLIDE EXAMINED
Month Day Year
DATE RESULT RELEASED
DRUGS GIVEN NUMBER NUMBER NUMBER

1. Chloroquine ___ tabs 4. Coartem ___ tabs 7. Others ________ _____
2. Sulfadoxine-pyrimethamine ___ tabs 5. Quinine ___ tabs 8. None
3. Primaquine ___ tabs 6. Antibiotics ___ tabs, specify ____________________________
Month Day Year

Date Given
SUPERVISED TREATMENT ON DAY 1 Yes No

CLASSIFICATIONS: 1. Probable - Uncomplicated Severe 2. Confirmed - Uncomplicated Severe
Remark(s): ______________________________________________________________________________________________
NAME OF HEALTH WORKER/ ______________________________________________________________________

DESIGNATION Last Name First Name M.I.
BHW MALARIA VOLUNTEER BM MHO Hospital Staff
Annex 2.10
RHM MMC FAW PHN
REFERRED TO _________________________________________________________
REASON FOR REFERRAL ________________________________________________
Tear Here
Month Day Year
DATE RESULT RELEASED Laboratory Result
Slide Number ___________
WHO/WHERE RESULT WILL
BE SENT TO ______________________________________________________ Microscopy RDT
STREET/BARANGAY ________________________________________________ Pf Pf
HOUSEHOLD HEAD ________________________________________________ Pv Pv
Last Name First Name M.I. Pm Neg
NAME OF PATIENT _________________________________________________ NMPS
Last Name First Name M.I. Clinical Diagnosis
AGE SEX Male Female

Year Month
Remark(s): ___________________________________________________________________________________________________
REFERRED TO: ______________________________________ REFERRED BY: _________________________________________
Annex 2 Leprosy
Leprosy Prevention and Control Program
INDIVIDUAL TREATMENT RECORD (ITR) Family Serial No.:_______
Name: ___________________________________ Sex: _________ Age: ________
Present Address: ______________________________ Civil Status: ______________________
Date of Birth: _____________________________ Place of Birth: ____________________
Name & Address of Nearest Relative: _____________________________________________________
Occupation: __________________________ Contact Number: __________________
Mode of Detection: Self Reporting ( ) Referral ( ) Household Contact Exam ( ) Special Project ( )
Signs: No. of patches with loss of sensation: _______________________________________________

Enlargement/tenderness of peripheral nerve/s: Yes ( ) How many? ____ No ( )
Positive smear (if done): Yes ( ) No ( )
Classification: PB ( ) MB ( ) Date Classified: __________ Date Treatment Started: __________
Type of Case: New ( ) Relapse ( ) Return After Default ( ) Reclassified ( ) Trans in ( )
HOUSEHOLD CONTACT EXAMINATIONS:
DATE OF EXAM/RESULT REMARKS

NAME OF HOUSEHOLD
AGE RELATIONSHIP SEX
CONTACT
Y1 Y2 Y3 Y4 Y5
DRUG COLLECTION CHART
GIVEN BY
DATE FOR THE REMARKS
TREATMENT (Initials)
SUPERVISED DOSE
PB MB
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Treatment Outcome:
Cured/Treatment Completed: Date: ________ Defaulted: Date: __________
Transferred Out: Date: __________________ Died: Date: _____________
Annex 2.11 Annex 4 Schistosomiasis
Schistosomiasis Prevention and Control Program

Family Serial No.______
I. GENERAL DATA:
NAME: _____________________________________ AGE: ______ SEX: ______

STATUS: Married___ Single ____ Widow/er ____ Separated _____
ADDRESS: ___________________________________CONTACT NO. ___________
II. SOCIO-ECONOMIC DATA:
1. Occupation: ________________________________________
2. Number of members in the household: ___________________
3. Sanitation & Hygiene Data:
3.1 With Sanitary toilet? Yes: _____ No: ____
3.2 With Access to safe Water Supply? Yes: ____ No: ____
III. PAST HISTORY OF EXPOSURE TO SCHISTOSOMIASIS ENDEMIC AREA?

Yes ____ No ____, If Yes pls. specify? ________________ How long? ________
1. History of past schisto infection?

Yes ____ No ____, if yes, When? _________________
2. Were you able to take the medication during that conclusive Schistosomiasis infection?
Yes ____ No ____, if yes, What meds? _________________________
IV. Chief Complaints: (please check any)
Abdominal pain __________

Bloody mucoid stool __________
Fever __________
Headache __________
Seizure __________
Others: __________
V. Vital signs & pertinent PE findings:
Wt: ____________ (kg)

BP: ____________ Pallor: _____________ Ascites: ______________
Temp: ____________ Hepatomegaly _____________ Others ______________
RR: ____________ Splenomegaly _____________
VI. Diagnosis: _______________________________________________________________
VII.
Laboratory Date Results Remarks
Examination
Stool Exam
1st
nd
2
Blood Exam
Urinalysis
Others
VIII. Action Taken _______________________________________________________________

Annex 5 Filariasis
Annex 2.12
Filariasis Prevention and Control Program
Family Serial No.______
PERSONAL DATA
NAME: ______________________________________ AGE: ____ SEX: ____ CIVIL
STATUS:____________
ADDRESS: _______________________________________________CONTACT NUMBER:
_______________
DURATION OF STAY AT ABOVE ADDRESS: _____ BIRTH PLACE:
_________________________________
OCCUPATION: ___________________________ PLACE OF WORK:
________________________________
CLINICAL DATA
CHIEF COMPLAINT:
________________________________________________________________________
HISTORY OF PRESENT ILLNESS:

Signs and Symptoms Location Frequency Duration
FEVER
BODY MALAISE/
HEADACHE/ CHILLS:
LYMPHADENITIS
RETROGRADE/RECURRENT
LYMPHANGITIS
HISTORY OF PAST FILARIA INFECTION:

BLOOD EXAMINATION (If done: Results):
_________________________________________________
TREATMENT:
________________________________________________________________________
REACTION:
_________________________________________________________________________
FAMILY HISTORY: (Other similar case/cases in the same household)

NAME AGE SEX OCCUPATION ADDRESS
1. ___________________________ ____ ____ ______________________
______________________
2. ___________________________ ____ ____ ______________________
______________________
3. . __________________________ ____ ____ ______________________
______________________
SOCIAL HISTORY:
PREVIOUS PLACES OF RESIDENCE (Inclusive Dates)
1.
_______________________________________________________________________________________
_
2.
_______________________________________________________________________________________
_
PREVIOUS OCCUPATION (Inclusive Dates)

1.
_______________________________________________________________________________________
_
2.
_______________________________________________________________________________________
_
PHYSICAL EXAMINATION FINDINGS:

Weight: ________ BP: ____________ Temp:______ Cardiac Rate: ______ Resp. Rate:
___________
LYMPHADENITIS (Specify/Location):
__________________________________________________________
LYMPHANGITIS (Specify/Location):
___________________________________________________________
LYMPHEDEMA (Specify/Location):
____________________________________________________________
ELEPHANTIASIS (Specify-Leg/Scrotum/Arm/Penis/Vulva/Breast)
____________________________________
_______________________________________________________________________________________
___
MANAGEMENT:
____________________________________________________________________________
_______________________________________________________________________________________
___
Service Provider: ________________________ Date Examined: __________________
Annex 2.13

INDIVIDUAL TREATMENT RECORD (ITR) FOLLOW-UP FORM

For All Children Under-Five Years of Age with Health Problems under IMCI or Non-
IMCI Classification/Other Children/Adults
(To be attached to the Initial ITR of the patient)
PATIENTS CASE SUMMARY
Patients Name__________________________________ Family Serial No:______

Date of Visit:_____________ Age (in months if under five years of age):________
I. Subjective Complaints(S/Sx):
Chief Complaint:
Present Illness:
Past History:
II. Objective Findings:
Vital signs: Heart Resp.

BP (if ____ Rate: _____ Rate: _____
Needed):
Temp: ____ Weight: ____ Height: _____
Physical Examination:
_________________________________________________________________________
___________________________________________________________________
______________________________________________________________________
Laboratory Results: ____________________________________________________
III. Assessment/Classification:
_________________________________________________________________________
___________________________________________________________________
______________________________________________________________________
IV. Follow-up Plan of Management: (Further Treat, Refer and Health Educate)
_________________________________________________________________________
_________________________________________________________________________
________________________________________________________________
_____________________________________
Name and Signature of Service Provider

Fhsis PDF

Diunggah oleh

Informasi Dokumen

Deskripsi Asli:

Judul Asli

Hak Cipta

Format Tersedia

Bagikan dokumen Ini

Bagikan atau Tanam Dokumen

Opsi Berbagi

Apakah menurut Anda dokumen ini bermanfaat?

Apakah konten ini tidak pantas?

Hak Cipta:

Format Tersedia

Fhsis PDF

Diunggah oleh

Hak Cipta:

Format Tersedia

Field Health Services

FHSIS VER. 2012

Public Health Surveillance and Informatics Division

The Field Health Services Information System (FHSIS) continues to

I am proud to present this update to enhance the data quality of the

ENRIQUE A. TAYAG, MD, FPSMID, PHSAE, CESO III

Enrique A. Tayag MD, PHSAE, FPSMID, CESO III

Vito G. Roque, Jr. RMT, MD, PHSAE

Vikki Carr D. de los Reyes, MD, PHSAE

Kristine Dianne T. Toledo, RN

Francis Raize Nicholas Bautista, RN

Dr. Florencia Apale Mr. Edgardo Erce

Dr. Anthony Calibo Ms. Ruth Martinez

Dr. Manuel Calonge Engr. Joselito Riego de Dios

Dr. Anthony Cu Dr. Genesis Samonte

Ms. Frances Precilla Cuevas Engr. Roland Santiago

Ms. Myrna Gurtiza Mr. James Valencia

Dr. Marian Lynn de Laza Ms. Gloria Rodriguez

Ms. Luz Campos Engr. Ma. Elizabeth Baba

Mr. Mariano Selorio Jr. Mr. Leonardo Bautista

Ms. Genoveva Vias Ms. Maria Angeles de Guzman

Ms. Suenia Loria Mr. Paulito Ofiasa, RN

Ms. Alma Dumasis Ms. Maria Luz dela Cuadra

Ms. Hermela Tan Ms. Delia Ramos

Ms. Lilia Mariano

1.2 Objectives of FHSIS ver. 2012

1.3 Principles of FHSIS ver. 2012

1.4 Components of FHSIS ver. 2012

2.1 RECORDING TOOLS:

2.1.1 Individual Treatment Record (ITR)

DELA CRUZ, ROSE M.

2106 Rizal Avenue, Siniloan, Laguna

2.1.2 Target Client List (TCL)

2.1.3 Summary Table

2.1.4 Monthly Consolidation Table (MCT)

2.2 REPORTING TOOLS:

2.2.1 The Monthly Form

2.2.1.1 Program Report (M1)

2.2.1.2 Morbidity Report (M2)

2.2.2 The Quarterly Form

2.2.2.1 Program Report (Q1)

2.2.2.2 Morbidity Report (Q2)

2.2.3 The Annual Forms (A-BRGY, A1, A2 & A3)

2.3 RECORDING AND REPORTING TOOLS GUIDE

Locus of Recording Reporting Tools Frequency Schedule of Submission

ITR Monthly Form Monthly every second week of succeeding

ST Quarterly Form Quarterly every third week of the first month

2.4 REPORTING FLOW:

TARGET CLIENT LIST:

2.5 Target Client List for Prenatal Care

Column 6 LAST NORMAL MENSTRUAL PERIOD /GRAVIDA-PARITY

Formula for Computing EDC:

Example: LMP = 4 14 2012

Column 10 - TETANUS TOXOID VACCINATION GIVEN Write in this column

TT2 4 weeks after first dose within the same pregnancy

TT3 6 months after TT2

Column 11 MICRONUTRIENT SUPPLEMENTATION This has 2 sub columns, iron and

T Term newborn infants delivered more than or equal to 37 weeks completed

PT Pre-term/Premature any newborn infants delivered less than 37 weeks

NOTE: First Trimester = the first 3 months (up to 12 weeks)

* Outcome: LB = Livebirth ** Health code: *** Attended by:

2.6 Target Client List for Post-Partum Care

* Outcome: LB = Livebirth Health code: * Attended by: