BHW Summary of Services Reporting Form

Province:_______________________________BHW Monthly Report

Municipality / City of:_____________________MONTH:
Name of BRGY:__________________________(____/____/_____)
Name of BHS:_________________________
Name of PUROK:_______________________
BHW Services Information Bllang ng Bllang ng dapat
Mag Serbisyo Sean & Referred Given Servces by nairekord sa TCL ifollow up ng Remarks
(A) HSO (B) (C) BHW (D)
PRENATAL CARE
Bagong buntis (new cases) X X X X X
1st tri
2nd tri
3rd tri
Bilang ng buntis (old cases)
Bilang ng buntis na may panganib na
naobserbahan
POSTPARTUM CARE
Bilang ng ina na bagong panganak
Bilang ng bagong panganak na may
panganib na naobserbahan
Bilang ng bagong panganak na gustong
magfamily planning
FAMILY PLANNING
Bilang ng babae (15-49 taon ) na
gumagmit ng family planning
Bilang ng gustong magfamily planning
(unmet need)
EXPANDED PROGRAM ON IMMUNIZATION
Bilang ng bagong silang na sanggol
Bilang ng bata na nadala sa BHS para sa bakuna: X X X X
New Cases
Follow up
NUTRITION
Bilang ng bata na nabigyan ng: X X X X X
EBF
Vitamin A
Deworming
IBA PA
Ubo 2 linggo o higit pa (new cases)
PWD (new cases)
Elderly (new cases)
Maternal Death
Newborn Death

Noted by:
Submitted by: ________________________________ ________________________________
BHW
Midwife

Approved by: ________________________________ Date: ________________________________

MHO
BAGONG BUNTIS (New Cases)

FIRST TRIMESTER
NAME AGE LMP DATE OF CHECK-UP
1
2
3
4
5

SECOND TRIMESTER
NAME AGE LMP DATE OF CHECK-UP
1
2
3
4
5

THIRD TRIMESTER
NAME AGE LMP DATE OF CHECK-UP
1
2
3
4
5

BILANG NG BUNTIS (OLD CASE)

NAME AGE LMP DATE OF CHECK UP
1
2
3
4
5
6
7
8
9
10
BILANG NG INA NA BAGONG PANGANAK
NAME AGE DATE OF CHECK-UP
1
2
3
4
5

BILANG NG BAGONG PANGANAK NA GUSTONG MAG FAMILY PLANNING

NAME AGE Method to be Use
1
2
3
4
5

BILANG NG BABAE (15-49 TAON) NA GUMAGAMIT NG FAMILY PLANNING

NAME AGE DATE Method to be Use
1
2
3
4
5
6
7
8
9
10

BILANG NG GUSTONG MAGFAMILY PLANNING (UNMENT NEED)

NAME AGE DATE Method to be Use
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2
3
4
5
BILANG NG BAGONG SILANG NA SANGGOL
NAME BIRTHDAY DATE
1
2
3
4
5

IMMUNIZATION New Cases

NAME Birthday Antigen Given Date Given

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3
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5
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7
8
9
10

Follow up
NAME Birthday Antigen Given Date Given

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12
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20

EXCLUSIVE BREASTFEEDING
NAME OF CHILD BIRTHDAY
1
2
3
4
5

# OF CHILDREN GIVEN VITAMIN A

NAME Birthday Antigen Given Date Given

1
2
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5
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8
9
10
11
12
13
14
15

# OF CHILDREN GIVEN DEWORMING TABLETS

NAME Birthday Antigen Given Date Given

1
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9
10