M1

FHSIS REPORT for the MONTH: ________ YEAR: _______

Name of Barangay: _______________________________
Name of BHS: _______________________________
Name of Municipality/City: _______________________________

BRGY
Name of Province: _______________________________
Projected Population of the Year: _______________________________
For submission to RHU/MHC

Section A. Family Planning Services and Deworming for Women of Reproductive Age
Total for WRA
A1. Modern FP Unmet Need Age Remarks
15-49 y/o
(Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 y/o 15-19 y/o 20-49 y/o
1. No. of WRA with unmet need for modern FP - Total

A2. Use of FP Method Current Users Acceptors Drop-outs Current Users New Acceptors
(Beginning Month) New Acceptors Other Acceptors (Present Month) (End of Month) (Present Month)
(Previous Month) (Present Month)
(Col. 1) (Col. 2) (Col. 3) (Col. 4) (Col. 5) (Col. 6) (Col. 7)
10-14 15-19 20-49 10-14 15-19 20-49 10-14 15-19 20-49 10-14 15-19 20-49 10-14 15-19 20-49 10-14 15-19 20-49
Total Total Total Total Total Total
y/o y/o y/o y/o y/o y/o y/o y/o y/o y/o y/o y/o y/o y/o y/o y/o y/o y/o
a. BTL - Total
b. NSV - Total
c. Condom - Total
d. Pills - Total
d.1 Pills-POP - Total
d.2 Pills-COC - Total
e. Injectables (DMPA/POI)-Tot.
f. Implant - Total
g. IUD (IUD-I and IUD-PP)-Tot.
g.1 IUD-I- Total
g.2 IUD-PP - Total
h. NFP-LAM - Total
i. NFP-BBT - Total
j. NFP-CMM - Total
k. NFP-STM - Total
l. NFP-SDM - Total
m. Total Current Users
Section B. Maternal Care and Services
Indicators Age Total Remarks Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col. 3) (Col. 4) (Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 10-14 15-19 20-49
B1. Prenatal Care
1. No. of pregnant women w/ 6. No. of pregnant women who completed
at least 4 prenatal check- doses of calcium carbonate
ups - Total supplementation - Total
2. No. of pregnant women 7. No. of pregnant women given
assessed of their nutritional iodine capsules – Total
status during the 1st tri. -Total 8. No. of pregnant women given one dose
a. Number of pregnant of deworming tablet - Total
women seen in the first 9. No. of pregnant women screened for
trimester who have normal syphilis - Total
BMI - Total 10. No. of pregnant women tested positive
b. No. of pregnant women for syphilis - Total
seen in the first trimester 11. No. of pregnant women screened for
who have low BMI - Total Hepatitis B - Total
c. No. of pregnant women 12. No. of pregnant women tested positive
seen in the first trimester for Hepatitis B - Total
who have high BMI-Total 13. No. of pregnant women screened for
3. No. of pregnant women for HIV - Total
the first time given at least 2 14. No. of pregnant women tested for
doses of Td vaccination-Total CBC or Hgb & Hct count - Total
4. No. of pregnant women for 15. No. of pregnant women tested for
the 2nd or more times given CBC or Hgb & Hct count diagnosed
at least 3 doses of Td with anemia - Total
vaccination (Td2 Plus) - Total 16. No. of pregnant women screened for
5. No. of pregnant women who gestational diabetes – Total
completed the dose of iron 17. No. of pregnant women tested positive
with folic acid for gestational diabetes – Total
supplementation - Total
B2. Intrapartum Care and Delivery Outcome
18. No. of deliveries – Total
20. No. of deliveries attended by skilled
M
19. No. of live births – Total health professionals - Total
F
a. No. of live births with a. No. of deliveries attended by a
normal birth weight - Total doctor - Total
b. No. of live births with low b. No. of deliveries attended by a
birth weight - Total nurse – Total
c. No. of live births with c. No. of deliveries attended by
unknown birth weight-Total midwives - Total
Indicators Age Total Remarks Indicators Age Total Remarks
(Col. 1) (Col. 2) (Col. 3) (Col. 4) (Col. 1) (Col. 2) (Col. 3) (Col. 4)
10-14 15-19 20-49 10-14 15-19 20-49
21. No. of health facility-based 23a. No. of vaginal deliveries – Total
deliveries - Total 23b. No. of deliveries by cesarean
a. No. of deliveries in section – Total
public health facility-Total 24a. No. of full-term births – Total
b. No. of deliveries in 24b. No. of pre-term births – Total
private health facility-Tot. 24c. No. of fetal deaths - Total
22. No. of non-facility-based 24d. No. of abortion/miscarriage - Total
deliveries - Total
B3. Postpartum and Newborn Care
25. No. of postpartum women 27. No. of postpartum women with
together with their newborn Vitamin A supplementation – Total
who completed at least 2
postpartum check-ups -
Total
26. No. of postpartum women
who completed iron with
folic acid supplementation -
Total
Section C. Child Care and Services
Indicators Male Female Total Remarks Indicators Male Female Total Remarks
(Col. 1) (Col. 2) (Col. 3) (Col. 4) (Col. 5) (Col. 1) (Col. 2) (Col. 3) (Col. 4) (Col. 5)
C1. Immunization Services for Newborns, Infants and School-Aged Children/Adolescents
1. CPAB - Total 11. PCV 1 - Total
2. BCG - Total 12. PCV 2 - Total
3. HepB, within 24 hours. - Total 13. PCV 3 - Total
4. DPT-HiB-HepB 1 - Total 14. MCV 1 - Total
5. DPT-HiB-HepB 2 - Total 15. MCV 2 - Total
6. DPT-HiB-HepB 3 - Total 16. FIC - Total
7. OPV 1 - Total 17. CIC - Total
8. OPV 2 - Total 18. Td, Grade 1 (November) - Total
9. OPV 3 - Total 19. MR, Grade 1 (November) - Total
10. IPV - Total 20. Td, Grade 7 (November) - Total
21. MR, Grade 7 (November) - Total
Indicators Male Female Total Remarks Indicators Male Female Total Remarks
(Col. 1) (Col. 2) (Col. 3) (Col. 4) (Col. 5) (Col. 1) (Col. 2) (Col. 3) (Col. 4) (Col. 5)
C2. Nutrition Services for Infants and Children
22. Newborns initiated on breastfeeding imme-
diately after birth lasting to 90 mins - Total 31. Proportion of MAM children age 0-59 months old
23. Preterm/LBW infants given iron
supplementation - Total a. admitted in SFP
24. Infants exclusively breastfed until 6th month -
Total b. cured
25. Infants 6 mos. old initiated to complementary
feeding with continued breastfeeding - Total c. defaulted
26. Infants 6 mos. old initiated to complementary
d. died
feeding but no longer or never been breastfed
- Total 32. Proportion of SAM children without complication age 0-59 months old

a. admitted in OTC
27. Infants 6-11 mos. given 1 dose of Vitamin A
100,000 I.U. - Total b. cured
28. Children 12-59 mos. old given 2 doses of
Vitamin A 200,000 I.U. - Total c. defaulted
29. Infant 6-11 months old who completed MNP
supplementation - Total d. died
30. Children 12-23 mos. who completed MNP
supplementation - Total

C3. Deworming Services for Infants, Children and Adolescents

31. 1-19 y/o given 2 doses of deworming drug - b. SAC, 5-9 y/o dewormed (2 doses) - Total
Total c. Adolescents, 10-19 y/o dewormed (2
a. PSAC, 1-4 y/o dewormed (2 doses) - Total doses) - Total
C4. Management of Sick Infants and Children
32. Sick Infants 6-11 mos. old seen - Total 36. Diarrhea cases 0-59 months old seen - Total
33. Sick Infants 6-11 mos. old received Vitamin 37. Diarrhea cases 0-59 months old received
A - Total ORS - Total
34. Sick Children 12-59 mos. old seen - Total 38. Diarrhea cases 0-59 mos. received ORS w/
35. Sick Children 12-59 mos. old received zinc - Total
Vitamin A - Total 39. Pneumonia cases 0-59 mos. old seen - Total
40. Pneumonia cases 0-59 mos. old completed
treatment - Total
Section D. Oral Care and Services
To be submitted Quarterly
Indicators Male Female Total Remarks Indicators Male Female Total Remarks
(Col. 1) (Col. 2) (Col. 3) (Col. 4) (Col. 5) (Col. 1) (Col. 2) (Col. 3) (Col. 4) (Col. 5)
1. Orally fit children 12-59 months old upon oral 6a. Adolescents 10-14 years old who received
exam plus orally fit after rehab - Total BOHC - Total
2. Clients 5 years old and above with cases 6b. Adolescents 15-19 years old who received
of DMFT - Total BOHC - Total
3. Infants 0-11 months old who received BOHC - 7. Adults 20-59 years old who received BOHC -
Total Total
4. Children 1-4 years old who received BOHC - 8. Senior citizens 60 years old and above who
Total received BOHC - Total
5. Children 5-9 years old who received BOHC - 10-14 15-19 20-49
Total Indicators Total Remarks
y/o y/o y/o
9. Pregnant women who received BOHC - Total
Section E. Infectious Disease Prevention and Control Services
Indicators Male Female Total Remarks Indicators Male Female Total Remarks
(Col. 1) (Col. 2) (Col. 3) (Col. 4) (Col. 5) (Col. 1) (Col. 2) (Col. 3) (Col. 4) (Col. 5)
E1. Filariasis Prevention and Control (to be reported annually)
E2. Schistosomiasis Prevention and Control
1. No. of patients seen - Total 6. No. of confirmed chronic cases - Total
2. No. of suspected cases seen - Total 7. No. of confirmed cases (acute and chronic) -
3. No. of acute clinically diagnosed cases - Total Total
4. No. of confirmed acute cases - Total 8. No. of cases treated - Total
5. No. of chronic clinically diagnosed cases - 9. No. of confirmed chronic cases referred to a
Total hospital facility - Total
E3. Soil Transmitted Helminthiasis Prevention and Control (other age groups reflected under Child Care and Maternal Care)
1. No. of WRA, 20-49 years old, who completed
2 doses of deworming tablet - Total
E4. HIV-AIDS/STI Prevention and Control (reflected under Maternal Care)
E5. Tuberculosis Prevention and Control
1. Number of notified TB cases, all forms - Total 3. Number of TB, all forms that are cured and
completely treated - Total
2. No. of registered bacteriologically confirmed 4. No. of registered bacteriology confirmed drug
drug resistant TB (RR/MDR-TB Cases) - resistant TB Cases (RR/MDR-TB) cured &
Total completed treatment - Total
E6. Malaria Prevention and Control
1. No. of patients with probable/clinically 2. No. of lab-confirmed Malaria deaths - Total
diagnosed Malaria and confirmed case-Total
• < 5 y/o - Total • < 5 y/o - Total
• ≥ 5 y/o - Total • ≥ 5 y/o - Total
E7. Leprosy Prevention and Control E8. Rabies Prevention and Control
1. No. of Leprosy cases on treatment during 1. No. of animal bites - Total
reporting period - Total
2. No. of newly detected cases during 2.. No. of deaths due to Rabies - Total
reporting period - Total
Section F. Non-Communicable Disease Prevention and Control Services
Indicators Male Female Total Remarks Indicators Male Female Total Remarks
(Col. 1) (Col. 2) (Col. 3) (Col. 4) (Col. 5) (Col. 1) (Col. 2) (Col. 3) (Col. 4) (Col. 5)
1. No. of adults risk-assessed using PhilPEN - 5. No. of adult women screened for Cervical
Total Cancer using VIA/Pap Smear - Total
2. Current smokers - Total 6. No. of adult women found positive / suspect for
3. Alcohol binge drinkers - Total Cervical Cancer using VIA or Pap Smear -
4. Overweight/Obese - Total Total
Indicators Male Female Total Remarks Indicators Male Female Total Remarks
(Col. 1) (Col. 2) (Col. 3) (Col. 4) (Col. 5) (Col. 1) (Col. 2) (Col. 3) (Col. 4) (Col. 5)
7. No. of adult women screened for breast mass 11. No. of senior citizens screened for visual
- Total acuity - Total
8. No. of adult women with suspicious breast 12. No. of senior citizens diagnosed with eye
mass - Total disease/s - Total
9. No. of newly-identified hypertensive adults - 13. No. of senior citizens who received one (1)
Total dose of PPV - Total
10. No. of newly-identified adults with Type 2 DM- 14. No. of senior citizens who received one (1)
Total dose of influenza vaccine - Total
Section G. Environmental Health and Sanitation Services
Indicators Total Remarks Indicators Total Remarks
(Col. 1) (Col. 2) (Col. 3) (Col. 1) (Col. 2) (Col. 3)
1. No. of HHs with access to basic safe water supply - Total 2. No of HHs with basic sanitation facility - Total
a. No. of HHs with Level I - Total a. No. of HH with pour/flush toilet connected to septic tank - Total
b. No. of HHs with Level II - Total b. No. of HHs with pour/flush toilet connected to community
c. No. of HHs with Level III - Total sewer/sewerage system or any other approved treatment
system - Total
c. No. of HHs with ventilated improved pit latrine (VIP) - Total
3. No. of industrial establishments issued with sanitary permit - Total
Section H. Mortality Section I. Natality
Indicators Male Female Total Remarks Indicators Male Female Total Remarks
(Col. 1) (Col. 2) (Col. 3) (Col. 4) (Col. 5) (Col. 1) (Col. 2) (Col. 3) (Col. 4) (Col. 5)
1. Total Deaths attach linelist on maternal, 1. Livebirths - Total CBR:
2. Maternal Deaths - Total underfive,infant,neonatal, fetal a. Livebirths among 15-19 y/o women-Tot. ABR:
3. Under-five Deaths - Total deaths
4. Infant Deaths - Total
5. Neonatal Deaths - Total
6. Fetal Deaths - Total
7. Early Neonatal Deaths - Total
8. Perinatal Deaths - Total