MASTER LIST OF WOMEN OF REPRODUCTIVE AGE AND ADOLESCENT WOMEN

MASTER LIST OF WOMEN OF REPRODUCTIVE AGE AND ADOLESCENT WOMEN FOR FAMILY PLANNING SERVICES
FOR THE QUARTER/YEAR: _______________________
Barangay: ___________________________ Name of BHS Midwife:________________________________________ Date Prepared: ________________________

Do you plan to have more Does this WRA

Name of WRA Birthday children? Fecundity Based on TCL on FP did WRA
No HH No. Address Age in Years SE Status Civil Status has MFP unmet
(FN, MI, LN) (MM/DD/YY) (Place a /) (Place a /)
need?
accept any modern FP method?

If col. Sb & 8c is / are you If col. 8b or 8c is / and

currently using any FP method? using col. 10 b ot 10 c,
would you like to shift to
modern method?
(Place a /)
(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13)
Not using any Place a
No
1: NHTS FP method / - if Yes Yes
2: Non-NHTS If Yes when? No Fecund Infecund If yes what type? (Place a /) Yes No X – if No
(13a)
(Put a /)
1 currently (Put a /)
(10c)
married
Now Spacing Limiting (9a) (9b) Modern Traditional Specify Date when
2 Non married (10a) (10b) Modern FP FP method
but in (8a) (8b) (8c)
(11a) (11b) method accepted?
relationship[ as
10-14 15-19 20-49 if married d/
Living-in
3 Non-married
and not in any
relationship
with a man

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
TOTAL