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Fhsis Template Sample
Fhsis Template Sample
BRGY
10-14 15-19
PRENATAL CARE
1. No. of pregnant women with AT LEAST 4 PRENATAL CHECK-UPS - Total 0 0
0 0
2. No. of pregnant women assessed of their nutritional status during the 1st trimester - 0 1
Total
0 1
a. No. of pregnant women seen in the first trimester who have NORMAL BMI - total 0 1
1
b. Number of pregnant women seen in the first trimester who have LOW BMI
(nutritionally at risk) 0 0
0 0
c. No. of pregnant women seen whose BMI were classified as OBESE/OVERWEIGHT or
have high BMI - normal cut off 0 0
0 0
3. No. of pregnant women for the first time given 2 doses of Td vaccination - Total 0 0
0 0
4. No. of pregnant women for the 2nd or more times given at least 3 doses of Td
vaccination (Td2 Plus) - Total 0 0
0 0
5. No. of pregnant women who completed the dose of IRON with FOLIC ACID
supplementation - Total 0 0
0 0
0 0
0 1
0 1
0 1
0 1
0 1
0 1
14. No. of pregnant women tested for CBC or Hgb&Hct count - Total 0 1
0 1
15.No. of pregnant women tested for CBC or Hgb&Hct count diagnosed with anemia -
Total 0 1
0 1
0 1
17. No. of pregnant women tested positive for gestational diabetes – Total 0 0
0 0
INTRAPARTUM CARE AND DELIVERY OUTCOME
0 0
a. No. of live births with NORMAL birth weight - Total 0 0
0
b. No. of live births with LOW birth weight - Total 0 0
0 0
c. No. of live births with UNKNOWN birth weight- Total 0 0
0 0
0 0
a. No. of deliveries attended by a DOCTOR- Total 0 0
0 0
c. No. of deliveries attended by MIDWIVES/ doctor- Total 0 0
0 0
0 0
b. No. of deliveries attended by OTHERS 0 0
0 0
0 0
b. No.delivered in RHUs-total 0 0
0 0
c1. BULAN LYING Ins( RECOME) 0 0
0 0
d. No.delivered in HOSPITAL- total 0 0
0 0
d1. PGGMH 0 0
0 0
d2. Others SPH,IDH,sordoc, BRRTH 0 0
0 0
e. No.delivered in DOH-LICENSED AMBULANCE-total 0 0
0 0
0 0
a. No. of deliveries in public health facility 0 0
0 0
b. No. of deliveries in private health facility 0 0
0 0
0 0
a. home-total 0 0
0 0
b.others-total 0 0
0 0
27. Type of Delivery
a. No. of vaginal deliveries – Total 0 0
0 0
b. No. of deliveries by CS – Total 0 0
0 0
0 0
b. No. of pre-term births – Total 0 0
0 0
c. No. of fetal deaths-Total 0 0
0 0
d. No. of abortion/ miscarriage - Total 0 0
0 0
0 0
30. No. of postpartum women who completed iron with folic acid supplementation -
Total 0 0
0 0
0 0
Total Deliveries = Deliveries by Skilled Health Professional and by Non Skilled health profes CORRECT CORRECT
NHTS CORRECT CORRECT
CORRECT CORRECT
Total Facility based deliveries = Total Deliveries by Skilled Health Prof CORRECT CORRECT
NHTS CORRECT CORRECT
NON-NHTS CORRECT CORRECT
Total Facility Based Deliveries = Public and Private Facilities CORRECT CORRECT
NHTS CORRECT CORRECT
NON-NHTS CORRECT CORRECT
Total NON Facility based deliveries = Deliveries by NON Skilled health professionals CORRECT CORRECT
NHTS CORRECT CORRECT
NON-NHTS CORRECT CORRECT
2 RHU
BRGY
20-49 Total
2 2
2 2
0
1
2
0
1 2
1 2
1 2
0 0
0
0
0 0
0
0 0
0
0 0
0
0
0
2 2
0
2 2
0
1 1
0
1 1
0
1 1
0
1 1
0
1 2
0
1 2
0
1 2
0
1 2
0
1 2
0
1 2
0
1 2
0
1 2
0
1 2
0
1 2
0
1 2
0
1 2
0
1 2
0
1 2
0
1 2
0
1 2
0
1 2
0
1 2
0
1 2
0
1
0
0 0
0
0 0
0
0
0
0
2 2
0 0
2 2
0
2 2
0 0
2 2
0
2 2
0
2 2
0 0
0
0
0 0
0
0
0 0
0
0 0
0
2 2
0
2 2
0 0
0
0 0
2 2
0
2 2
0
0 0
0 0
0 0
0 0
0
0 0
0 0
0
0 0
0
2 2
0 0
2 2
0 0
0
0 0
2 2
0
2 2
0 0
0
0 0
0 0
0
0 0
0 0
0
0
0 0
0
0 0
0 0
0
0
0 0
0
0 0
0
2 2
0
2 2
2 2
0
2 2
0 0
0
0 0
0
0 0
0
0 0
0 0
0
0 0
0 0
0
0 0
0
0
2 2
0
2 2
0 0
0
0
0
0
2 2
0
2 2
0 0
0
0
0 0
0
0
0 0
0
0
0
0
0
2 2
0
2 2
0
2 2
0
2 2
0
0 0
0
2 2
CORRECT CORRECT
CORRECT CORRECT
CORRECT CORRECT
CORRECT CORRECT
CORRECT CORRECT
CORRECT CORRECT
CORRECT CORRECT
CORRECT CORRECT
CORRECT CORRECT
CORRECT CORRECT
CORRECT CORRECT
CORRECT CORRECT
CORRECT CORRECT
CORRECT CORRECT
CORRECT CORRECT
CORRECT CORRECT
CORRECT CORRECT
CORRECT CORRECT
CORRECT CORRECT
CORRECT CORRECT
CORRECT CORRECT
CORRECT CORRECT
CORRECT CORRECT
CORRECT CORRECT
BARANGAY
INDICATORS M F TOTAL
5. Newborns initiated on
breastfeeding
immediately after birth
lasting for at
least 90 minutes - Total 0 2 2
0
0 2