TCL

No.

Date

Date

of

of

Registration

Birth

Serial

mm/dd/yy

mm/dd/yy

Number

Family

*NHTS

FOR

NUTRITION

Name of Child
(mm/dd/yy)

&

EPI

PROGRAM

Wt Lgth Sex Complete Name

kgs

Hght F/M

of Mother

Complete

Address

PART

II

Newborn
Screening
Referral

Done

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
*NHTS - indicate infant belongs to the
CCT/NHTS family listed by DSWD

**Child protected at birth refers to a child whos (1) mother has received 2 d
of TT during pregnancy provided TT2 was given at least a month prior to de
or (2) Mother has received at least 3 doses of TT anytime prior to pregnancy
this child.
Date Assess - refers to the month and year the child was classified as CPAB based on the definition
Length - taken for children under 2 years of age

Height - taken for children 2 years and above

TCL

TT Status

Date

Date

Assess

s received 2 doses
th prior to delivery
to pregnancy with

definition

NUTRITION

&

EPI

DATE IMMUNIZATION RECEIVED

**Child Protected at
Birth (CPAB)

FOR

NO.

HEPA B1
BCG

w/ in

> 24

24 hrs

hrs

PENTAVALENT
1

OPV
3

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15

FIC - FULLY IMMUNIZED CHILD

is a child who has received all of the following antigens before reaching 1 year old:

a. 1 dose of BCG at birth or anytime,

b. 3 doses of OPV, 3 doses of Pentavalent Vaccines; and
c. 1 dose of Measles-containing vaccine (MCV1).

MCV
3

IPV

AMV

MMR

PROGR

PROGRAM
DATE

PART

TCL

PCV

EBF (X/)

Date

C. FEEDING
REMARKS

FIC

No.

2
3
4
5
6
7
8
9
10
11
12
13
14
15

EXCLUSIVE BREASTFEEDING -

no other food (including water) other than breastmilk.

no other food (including water) other than breastmilk.

Drops of vits & prescribed meds given while breastfeeding is still "exclusively breastfed."
infants 6-8 mos who received solid, semi-solid or soft
COMPLEMENTARY FEEDING foods to complement breastfeeding;

ofName

Wt

of Child

Registration Birth
(mm/dd/yy)
(mm/dd/yy)
(mm/dd/yy)

EXCLUSIVE BREASTFEEDING -

of

Date

(kgs)

FOR

CL

FOR

Length/

Height

NUTRITION

&

EPI

of MotherAddress

PART

Micronutrient Supplementation

Sex Complete Name

Complete

(F/M)

PROGRAM
Vit. A

6-11
mos.

Iron

12-59 mos.
Dose 1

Dose 2

De-

MNP

6-11

12-59

6-11

12-59

mos.

mos.

mos.

mos.

Remarks
worming

Registration
(mm/dd/yy)

Date

Date

of

of

Name of Child

Registration Birth

(mm/dd/yy)
(mm/dd/yy)

(mm/dd/yy)

TCL

FOR

PRENATAL CARE

DATE
OF

NO.
REGISTRATION

LMP
NHTS

NAME

(MM/DD/YY)

ADDRESS AGE

EDC

(MM/DD/YY)

G-P-A

(MM/DD/YY)

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15

NOTE:

1ST TRIMESTER
2ND TRIMESTER
3RD TRIMESTER

- the 1st 3mos ( up to 12 weeks )

- the middle 3 months ( 13-27 weeks )
- the last 3 months ( 28 weeks & more )

PART

DATE OF PRENATAL
1ST TRIMESTER

2ND TRIMESTER

TCL

NATAL VISITS

TETANUS

TOXOID

TT

NO.

3RD TRIMESTER

STATUS

RISK
CODE

FOR

PRENATAL CARE

MICRONUTRIENT SUPPLEMENTAT

DATE

DATE & NUMBER OF IRON

DETECTED

WITH FOLIC ACID WAS GIVEN

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15

RISK CODE:
A = an age < 18 or > 35 y.o.
B = being < 145cm ( 4' 9") tall
C = having a 4th (or more)
babies or so called grandmulti

D = have / has 1 or more of the following:

a. A previous Caesarian Section
b. 3 consecutive miscarriages/stillborn baby
c. Postpartum hemorrhage

E=

CARE

PART

EMENTATION
IRON

2
PREGNANCY

ACTUAL
DOD

S GIVEN

OUT-

(mm/dd/yy) COME

E = 1 or more of the ff:

1.
2.
3.
4.
5.

Tubersulosis
Heart Disease
Diabetes Mellitus
Bronchial Asthma
Goiter

GENDER
(M/F)

LIVE BIRTHS
TYPE

BIRTH PLACE

(NSVD)

WT

ATTEND-

OF

(CS) (grams)
DELIVERY

OUTCOME:

LB = Live Birth
SB = Still Birth
AB = Abortion

ED

REMARKS

BY

ATTENDANT:
A = Doctor
B = Nurse
C = Midwife
D = Hilot / TBA
E = Others

MONTH
JANUARY 2016
FEBRUARY 2016
MARCH 2016
APRIL 2016
MAY 2016
JUNE 2016
JULY 2016
AUGUST 2016
SEPTEMBER 2016
OCTOBER 2016
NOVEMBER 2016
DECEMBER 2016

TOTAL NUMBER
OF PREGNANT

TOTAL NUMBER
OF PREGNANT
WITH COMPLICATION

TOTAL NUMBER OF DUE

TOTAL NUMBER

THIS MONTH

OF DELIVERIES

SUM TOTAL

REMARKS

TCL
DATE
NO.

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
21
22
23
24
25

FOR

POSTPARTUM VISITS

TIME

OF

OF

DELIVERY

DELIVERY

(MM/DD/YY)

(HH:MM)

POSTPARTUM CARE

NAME

ADDRESS

DATE & TIME

W/ IN 24 HRS

W/ IN ONE

INITIATED

AFTER

WEEK AFTER

BREASTFEEDING

DELIVERY

DELIVERY

(MM/DD/YY)

(HH:MM)

MICRONUTRIENT
SUPPLEMENTATION
IRON
DATE/# OF TABLETS

TARGET CLIENT LIST FOR FAMILY PLANNING

ONUTRIENT
EMENTATION
VIT. A

REMARKS

NO.

DATE
OF REGISTRATION

NAME

(MM/DD/YY)

DATE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15

PREVIOUS METHOD:
CON= Condom

NFP-STM = Symptothermal Method

INJ= DMPA/CIC

NFP-LAM = Lactational Amenorrhea Method

PILLS= Pills

IUD=Intra-Uterine Device (PP-IUD/I-IUD)

NONE / NA

MSTR/VASEC= Male Ster./ Vasectomy

ENT LIST FOR FAMILY PLANNING

FP METHOD : _________________

ADDRESS

BIRTHDATE

AGE

(MM/DD/YYYY)

SDM= Standard Days Method

TYPE OF CLIENT:

TYPE
OF CLIENT

PREVIOUS
METHOD

(USE CODES)

(USE CODES)

CU = Current User

FSTR/BTL= Bilateral Tubal Ligation

NA

= New Acceptor

IMP= Single Rod Sub-Thermal Implant

CU-CM

= Changing Method

NFP-BBT= Basal Body Tenperature

CU-CC

= Changing Clinic

NFP-CM= Cervical Mucus Method

CU-RS

= Restarter