1 ALL M1 G1 Need to encode all the data needed in the whole sheet

2 All M1 G2 highighted in YELLOW B 1, 2a-c

3 All M1 G3 highighted in YELLOW All 18-22 and 24 a-d
 FHSIS REPORT for the MONTH: __________________ YEAR: ______________

M1
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
Total for 15-49 y/o
(Col. 1) (Col. 2) WRA (Col. 3) (Col. 4)
Unmet
10-14 y/o 15-19 y/o 20-24y/o 25-49y/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- 25-49 10-14 15-19 20- 25-49 10-14 15-19 20- 25-49 10-14 15-19 20- 25-49 10-14 15-19 20- 25-49 10-14 15-19 20- 25-49
Total Total Total Total Total Total
y/o y/o 24y/o y/o y/o y/o 24y/o y/o y/o y/o 24y/o y/o y/o y/o 24y/o y/o y/o y/o 24y/o y/o y/o y/o 24y/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

2
FHSIS REPORT for the MONTH: __________________ YEAR: ______________
Name of Barangay: _______________________________
Name of BHS: _______________________________
Name of Municipality/City: _______________________________
Name of Province: _______________________________
Projected Population of the Year: _______________________________
For submission to RHU/MHC

3
 Section B. Maternal Care and Services
Indicators Age Total Remarks Indicators
(Col. 1) (Col. 2) (Col. 3)  (Col. 4) (Col. 1)
10-14 15-19 20- 25-49 10-14
y/o y/o 24y/o y/o y/o
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
of deworming tablet - Total
a. Number of pregnant
women seen in the first
trimester who have normal 9. No. of pregnant women screened for
BMI - Total syphilis - Total

10. No. of pregnant women tested positive

for syphilis - Total
b. No. of pregnant women
seen in the first trimester
who have low BMI - Total 11. No. of pregnant women screened for
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
HIV - Total
3. No. of pregnant women for
the first time given at least 2
doses of Td vaccination-Total 14. No. of pregnant women tested for
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
4
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

gestational diabetes – Total
5. No. of pregnant women who
completed the dose of iron
with folic acid 17. No. of pregnant women tested positive
supplementation - Total for gestational diabetes – Total

5
EAR: ______________

M1
_
_
__

BRGY
_
__
MHC

6
ernal Care and Services
Age Total Remarks
(Col. 2) (Col. 3)  (Col. 4)
15-19 20- 25-49
y/o 24y/o y/o

7
8
FHSIS REPORT for the MONTH: __________________ YEAR: ______________
Name of Barangay: _______________________________
Name of BHS: _______________________________
Name of Municipality/City: _______________________________
Name of Province: _______________________________
Projected Population of the Year: _______________________________
For submission to RHU/MHC

9
B2. Intrapartum Care and Delivery Outcome
20. No. of deliveries attended by skilled
18. No. of deliveries – Total
health professionals - Total
19. No. of live births – Total a. No. of deliveries attended by a doctor - Total
a. No. of live births with b. No. of deliveries attended by a
normal birth weight - Total nurse – Total
b. No. of live births with low c. No. of deliveries attended by
birth weight - Total midwives - Total
c. No. of live births with d. No. of deliveries attended by
unknown birth weight-Total hilots - Total
Indicators Age Total Remarks Indicators
(Col. 3)  (Col. 4)
(Col. 1) (Col. 2) (Col. 1)
10-14 15-19 20- 25-49 10-14
y/o y/o 24y/o y/o y/o
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

10
EAR: ______________

M1
_
_
__

BRGY
_
__
MHC

11
 Age Total Remarks
(Col. 3)  (Col. 4)
(Col. 2)
15-19 20- 25-49
y/o 24y/o y/o

12