RURAL HEALTH UNIT AND BIRTHING FACILITY

OPERATION TIMBANG POLANGUI, ALBAY

AGE IN NUTRIONAL
DATE MONTHS WEIGHT HEIGHT STATUS
CHILD IMMUNIZATION RECORD
PUROK:______BARANGAY:_________________________
NAME OF CHILD:________________________________________
DATE OF BIRTH:______________________AGE:______________
PLACE OF BIRTH:______________________

NAME OF MOTHER:_____________________________________
AGE:______________GRAVIDA/PARA:_____________
TT STATUS:____TT1____TT2____TT3____TT4____TT5
EDUCATIONAL ATTAINMENT:_____________________________
OCCUPATION:______________

NAME OF FATHER:____________________AGE:______________
EDUCATIONAL ATTAINMENT:_____________________________
OCCUPATION:______________

GESTATIONAL AGE AT BIRTH: TYPE OF BIRTH:

BIRTH ORDER:_________ BIRTH ATTENDANT

BIRTH WEIGHT:________ ____DOCTOR ___NURSE
BIRTH LENGTH:________ ____MIDWIFE ___OTHERS

RURAL HEALTH UNIT AND BIRTHING FACILITY

OPERATION TIMBANG POLANGUI, ALBAY
AGE IN NUTRIONAL
DATE MONTHS WEIGHT HEIGHT STATUS
CHILD IMMUNIZATION RECORD
PUROK:______BARANGAY:_________________________

NAME OF CHILD:________________________________________
DATE OF BIRTH:______________________AGE:______________
PLACE OF BIRTH:______________________

NAME OF MOTHER:_____________________________________
AGE:______________GRAVIDA/PARA:_____________
TT STATUS:____TT1____TT2____TT3____TT4____TT5
EDUCATIONAL ATTAINMENT:_____________________________
OCCUPATION:______________

NAME OF FATHER:____________________AGE:______________
EDUCATIONAL ATTAINMENT:_____________________________
OCCUPATION:______________

GESTATIONAL AGE AT BIRTH: TYPE OF BIRTH:

BIRTH ORDER:_________ BIRTH ATTENDANT
BIRTH WEIGHT:________ ____DOCTOR ___NURSE
BIRTH LENGTH:________ ____MIDWIFE ___OTHERS
 PETSA
BAKUNA LABAN SA SAKIT NA: REMARKS
1ST DOSE 2ND DOSE 3RD DOSE

BCG Tuberculosis

HEPA B @ BIRTH Hepatitis B

Dipterya, Tetano, Pertusis,

PENTAVALENT( DPT, HEP B, HIB) Hepatitis B, Pulmonya,
Meningitis

ORAL POLIO VACCINE(OPV) Polio

INACTIVATED POLIO VACCINE(IPV) Polio

PNEUMOCOCCAL CONJUGATE Pulmonya, Meningitis

VACCINE 13(PCV13)
MEASLES CONTAINING VACCINE Tigdas/ Beke/ German
(AMV, MR, MMR) measles
IBA PANG BAKUNA:

Xeropthalmia, Panlalabo ng mata

VITAMIN A SUPPLEMENTATION
DEWORMING (kada 6 na buwan) Parasitismo/Helminthiasis

PETSA
BAKUNA LABAN SA SAKIT NA: REMARKS
1ST DOSE 2ND DOSE 3RD DOSE
BCG Tuberculosis

HEPA B @ BIRTH Hepatitis B

Dipterya, Tetano, Pertusis,
PENTAVALENT( DPT, HEP B, HIB) Hepatitis B, Pulmonya,
Meningitis

ORAL POLIO VACCINE(OPV) Polio

INACTIVATED POLIO VACCINE(IPV) Polio

PNEUMOCOCCAL CONJUGATE Pulmonya, Meningitis

VACCINE 13(PCV13)
MEASLES CONTAINING VACCINE Tigdas/ Beke/ German
(AMV, MR, MMR) measles
IBA PANG BAKUNA:

Xeropthalmia, Panlalabo ng mata

VITAMIN A SUPPLEMENTATION
DEWORMING (kada 6 na buwan) Parasitismo/Helminthiasis
 RURAL HEALTH UNIT AND BIRTHING FACILITY
FP METHOD:_____________________________ POLANGUI, ALBAY

DATE OF GIVEN BY:

DATE GIVEN FOLLOW UP NAME SIGNATURE FAMILY PLANNING RECORD
PUROK:___________BARANGAY:___________________

NAME OF CLIENT:_____________________________________
DATE OF BIRTH:_____________AGE:_________________
CIVIL STATUS:______________ RELIGION:______________
EDUCATIONAL ATTAINMENT:_____________________________
OCCUPATION:_____________________________________
PHILHEALTH NO:____________________________________
NHTS: ________YES ________NO

NAME OF SPOUSE:__________________________________
DATE OF BIRTH:_______________________________________
AGE:_____________ RELIGION:__________________________
EDUCATIONAL ATTAINMENT:__________________________
OCCUPATION:_______________________________________
PHILHEALTH NO:_______________________________________
AVERAGE MONTHLY INCOME:_________________________

NO. OF LIVING CHILDREN:____________________________

PLAN TO HAVE MORE CHILDREN: ______YES ______NO

RURAL HEALTH UNIT AND BIRTHING FACILITY

FP METHOD:_____________________________ POLANGUI, ALBAY

DATE OF GIVEN BY:

DATE GIVEN
FOLLOW UP NAME
SIGNATURE FAMILY PLANNING RECORD
PUROK:___________BARANGAY:___________________

NAME OF CLIENT:_____________________________________
DATE OF BIRTH:_____________AGE:_________________
CIVIL STATUS:______________ RELIGION:______________
EDUCATIONAL ATTAINMENT:_____________________________
OCCUPATION:_____________________________________
PHILHEALTH NO:____________________________________
NHTS: ________YES ________NO

NAME OF SPOUSE:__________________________________
DATE OF BIRTH:_______________________________________
AGE:_____________ RELIGION:__________________________
EDUCATIONAL ATTAINMENT:__________________________
OCCUPATION:_______________________________________
PHILHEALTH NO:_______________________________________
AVERAGE MONTHLY INCOME:_________________________
NO. OF LIVING CHILDREN:____________________________
PLAN TO HAVE MORE CHILDREN: ______YES ______NO
_____

___________
______
________
_______________
________
_________

_________
___________
___________
_________
__________
______________
_________

_________

_____

___________
______
________
_______________
________
_________

_________
___________
___________
_________
__________
______________
_________
_________
 FP METHOD:_____________________________
TYPE OF CLIENT
DATE OF GIVEN BY:
DATE GIVEN FOLLOW SIGNATURE
_____ NEW ACCEPTOR UP NAME
_____CURRENT USER
___CHANGING METHOD
___CHANGING CLINIC
___DROP OUT/ RESTART

REASONS FOR FP:

____ SPACING
____ LIMITING
____ OTHERS

PREVIOUSLY USED METHOD (For Current User)

____IMPLANT ____IUD ____BTL
____INJECTABLE ____COC ____BBT
____LAM ____POP ____NSV
____STM ____SDM ____CONDOM
____BOM/CMM ____OTHERS

FP METHOD:_____________________________
TYPE OF CLIENT
DATE OF GIVEN BY:
DATE GIVEN FOLLOW SIGNATURE
_____ NEW ACCEPTOR UP NAME
_____CURRENT USER
___CHANGING METHOD
___CHANGING CLINIC
___DROP OUT/ RESTART

REASONS FOR FP:

____ SPACING
____ LIMITING
____ OTHERS

PREVIOUSLY USED METHOD (For Current User)

____IMPLANT ____IUD ____BTL
____INJECTABLE ____COC ____BBT
____LAM ____POP ____NSV
____STM ____SDM ____CONDOM
____BOM/CMM ____OTHERS
 REFERRAL RURAL HEALTH UNIT AND BIRTHING FACILITY-POLANGUI
PROBLEMS IDENTIFIED, OTHER LABORATORY RESULTS HOME BASED MOTHER'S RECORD
(ECG, URINALYSIS, RPR/VDRL, HBSaG,CBC,etc)
NAME:_____________________B-DAY:_______________
ADDRESS___________________AGE:________________
CONTACT NO:________________CIVIL STATUS:_______________
PHILHEALTH NO._____________BLOOD TYPE:________________
NAME OF HUSBAND:___________________________________
AGE:_____________ CONTACT NO:__________________________

OBSTETRICAL HISTORY
PREVIOUS CEASERIAN SECTION NO YES
FINDINGS, ACTIONSTAKEN, AND INSTRUCTION GIVEN 3 CONSECUTIVE MISCARRIAGES NO YES
STILLBIRTH NO YES
POST-PARTUM HEMORRHAGE NO YES

PRESENT HEALTH PROBLEMS

TUBERCULOSIS NO YES
HEART DISEASE NO YES
DIABETES NO YES
ASTHMA NO YES
GOITER NO YES

REFERRAL RURAL HEALTH UNIT AND BIRTHING FACILITY-POLANGUI

HOME BASED MOTHER'S RECORD
PROBLEMS IDENTIFIED, OTHER LABORATORY RESULTS
(ECG, URINALYSIS, RPR/VDRL, HBSaG,CBC,etc)

NAME:_____________________B-DAY:_______________
ADDRESS___________________AGE:________________
CONTACT NO:________________CIVIL STATUS:_______________
PHILHEALTH NO._____________BLOOD TYPE:________________
NAME OF HUSBAND:___________________________________
AGE:_____________ CONTACT NO:__________________________

OBSTETRICAL HISTORY
PREVIOUS CEASERIAN SECTION NO YES
FINDINGS, ACTIONSTAKEN, AND INSTRUCTION GIVEN 3 CONSECUTIVE MISCARRIAGES NO YES
STILLBIRTH NO YES
POST-PARTUM HEMORRHAGE NO YES

PRESENT HEALTH PROBLEMS

TUBERCULOSIS NO YES
HEART DISEASE NO YES
DIABETES NO YES
ASTHMA NO YES
GOITER NO YES
LMP:______________________EDC:_______________________ GRAVIDA:____PARITY:______
TT1:__________ TT2:_________TT3:________TT4________ TT5:__________
NO. 0F VAGINAL
VISIT DATE BP HT WT AOG FH FHT TT IRON EDEMA UTI BLEEDING PRESENTATION REMARKS

1
2
3
4
5
6
7
8
9

BIRTH and EMERGENCY PLAN

Saan mo plano manganak:_______________________ Sino ang magpapaanak sayo:___________________________________
Ilan ang magagastos: Paraan ng pagbabayad:
Philhealth accreditted:_____Oo:____ Hindi ______________________ __________________

Sasakyang gagamitin:________________________ Sasamahan ako ni:__________________________________

Maaaring magbigay ng dugo sa akin ay sina: Relasyon:_________________Contact No:________________________
Pangalan:____________________________ Tirahan:__________________Contact No:_______________________
Pangalan:____________________________ Tirahan:__________________Contact No:_______________________
POST NATAL CARE
Petsa ng Panganganak:_______ Paraan ng Panganganak:___________Saan Nanganak:____________________________
Kasarian ng Anak:__________ WEIGHT:_________ LENGTH:_____________BCG:___________ HEP B:_____________
EBF:____________ Iba pang Kundisyon:__________________________ VIT.K:__________ OTHERs:___________

LMP:______________________EDC:_______________________ GRAVIDA:____PARITY:______
TT1:__________ TT2:_________TT3:________TT4________ TT5:__________
NO. 0F VAGINAL
VISIT DATE BP HT WT AOG FH FHT TT IRON EDEMA UTI BLEEDING PRESENTATION REMARKS

1
2
3
4
5
6
7
8
9

BIRTH and EMERGENCY PLAN

Saan mo plano manganak:_______________________
Philhealth accreditted:_____Oo:____ Hindi
Sasakyang gagamitin:________________________
Maaaring magbigay ng dugo sa akin ay sina:
Pangalan:____________________________
Pangalan:____________________________
Sino ang magpapaanak sayo:___________________________________
Ilan ang magagastos: Paraan ng pagbabayad:
______________________ __________________
Sasamahan ako ni:__________________________________
Relasyon:_________________Contact No:________________________
Tirahan:__________________Contact No:_______________________
Tirahan:__________________Contact No:_______________________

POST NATAL CARE

Petsa ng Panganganak:_______ Paraan ng Panganganak:___________Saan Nanganak:____________________________
Kasarian ng Anak:__________ WEIGHT:_________ LENGTH:_____________BCG:___________ HEP B:_____________
EBF:____________ Iba pang Kundisyon:__________________________ VIT.K:__________ OTHERs:___________