WEEK ____

GENERAL OBJECTIVE AND SPECIFIC OBJECTIVES (GOSO)

Name: ________________________________ Date: ___________________

Area: _________________________________ Day/Shift: ________________
Clinical Instructor: _______________________ Activity: ________________

GENERAL OBJECTIVE

SPECIFIC OBJECTIVES
Knowledge:
1.

2.

3.

Skills:
1.

2.

3.

Attitude:
1.

2.

3.

DAILY PLAN OF ACTIVITIES

ACTIVITIES
TIME

No part of this activity worksheet should be reproduced without the knowledge of the author.
Property of CMU College of Nursing Level 2 Faculty.
 Central Mindanao University
University Town, Musuan, Maramag Bukidnon
College of Nursing

ACTIVITY WORKSHEET ___:

FAMILY PLANNING METHODS

Name: _________________________________________ HRN: ____________

LAST NAME FIRST NAME MIDDLE NAME

Age: _____ Gender: _______ Status: _______ Contact #: ____________

Address: ___________________________________________________________
PUROK BARANGAY MUNICIPALITY PROVINCE

Name of Spouse: _____________________________ Contact #: ____________

Clinical History and Physical Examination

Blood Type: _________ Rh ( ) Age of Menarch: _______________
Hepatitis B Ag: Reactive LMP: _______________
Non-reactive
Allergies: ___________________ Obstetric Score:
G___ P___ (T___ P___ A___ L___)

Personal History Smoking Alcohol Drinking Drug Abuse

OB History
DATE OF FAMILY HOW LONG COMMENTS/
CHILD GA UPON BIRTH TYPE OF
DELIVERY GENDER PLANNING DID YOU COMPLICATIO
# DELIVERY WEIGHT DELIVERY
(M/D/Y) USED USED IT NS

Type of Client
New Acceptor Reasons for FP: Spacing Limiting
Others _______________
Current User
Changing Method Reasons: Medical Condition
Changing Clinic Side-effects
Restart/Dropout Specify: _______________

Method currently used (for Changing Method):

COC Pills IUD
Progesterone-only Pills Condom
Injectable Cervical Mucus Method
Implant Body Basal Temperature
Sympto-thermal Method Lactating Amenorrhea Method
Standard Days Method Others: _____________________

No part of this activity worksheet should be reproduced without the knowledge of the author.
Property of CMU College of Nursing Level 2 Faculty.
Family Planning Client Assessment Record
Date of Medical Findings Name/Sig Date of
Method
Visit Vital Signs (Observations, complaints, procedure, of Health Follow-up
laboratory, treatment & referrals) Accepted
MM/DD/YR Worker MM/DD/YR
T-
P-
R-
BP-
Wt-
Ht-

T-
P-
R-
BP-
Wt-
Ht-

T-
P-
R-
BP-
Wt-
Ht-

Health Education Given

Topic/Session Date Mother’s Signature

_________________________________ _______________________
Name of Student Nurse/Signature Date

No part of this activity worksheet should be reproduced without the knowledge of the author.
Property of CMU College of Nursing Level 2 Faculty.
 LEARNING FEEDBACK DIARY

LEARNINGS PROBLEMS ENCOUNTERED ACTIONS TAKEN REALIZATION

SELF

PEERS

POPULATION
GROUP/
COMMUNITY

CLINICAL
INSTRUCTOR

No part of this activity worksheet should be reproduced without the knowledge of the author.
Property of CMU College of Nursing Level 2 Faculty.