MUNICIPALITY OF:
PROVINCE/CITY:
REGION:
FHSIS v. 2012
TARGET CLIENT LIST FOR PRENATAL CARE
TCL-PN
DATE OFFAMILY D A T
REGIS- SERIAL LMP EDC PRENATAL
NAME ADDRESS AGE
TRATION NO. mm/dd/yy (mm/dd/yy) (8)
mm/dd/yy G-P FIRST
(1) (2) (3) (4) (5) (6) (7) TRIMESTER
NOTE: First Trimester = the first 3 months (up to 12 weeks or 0-84 day
Second Trimester = the middle 3 months (13-27 weeks or 85-18
Third Trimester = the last 3 months (28 weeks and more or 190 d
15
D A T E
PRENATAL VISITS
(8)
SECOND THIRD
TRIMESTER TRIMESTER
16
17
TARGET CLIENT LIST FOR PRENATAL CARE
DATE TETANUS TOXOID VACCINE MICRONUTRIENT SUPPLEMENTATION STI SURVEILLANCE PREGNANCY LIVEBIRTHS
TETANUS GIVEN (11) (12) (13) (14)
STATUS BIRTH PLACE OF
(10) DATE & NUMBER
TESTED RESULT FOR GIVEN OUT- DELIVERY
FOR SY SY TESTING PENICILLIN DATE
(9) IRON W/ FOLIC ACID COME*/G WEIGHT
TERMI- Health
ender NID
Y/N NATED
TT1 TT2 TT3 TT4 TT5 WAS GIVEN DATE (+/-) / DATE (M/F) (grams) Facility**
Date
REMARKS
ATTENDED
BY***
(15)
tended by:
MD = Doctor
RN = Nurse
RM= Midwife
H = Hilot/TBA
O = Others
BEMOC, CEMOC)
hers.
FHSIS TARGET CLIENT LIST FOR PRENATAL CARE
DATE OF FAMILY D A T
REGIS- SERIAL LMP EDC PRENATAL
NAME ADDRESS AGE
TRATION NO. mm/dd/yy (mm/dd/yy) (8)
mm/dd/yy G-P FIRST
PREGNANCY LIVEBIRTHS
(13) (14)
PLACE OF REMARKS
OUT- BIRTH
DELIVERY
COME*/G WEIGHT ATTENDED
ender Health BY***
NID
(M/F) (grams) Facility**
(15)