Republic of the Philippines

Department of Health
OFFICE OF THE SECRETARY

HEALTH FACILITY MONTHLY UTILIZATION/STOCK INVENTORY REPORT FORM

for Public Health Pharmacists Inventory Notes

Name of Health Facility Province Date of Monitoring

Municipality Region

Stock Transfer
Deliveries
Ending (DM-2014-0317)
inventory
from the Quantity Monthly Quantity End of Month Stocks
DOH MAINTENANCE MEDICINES PREVIOUS Expired
Quantity
QTY
Received QTY Transfer
Consumption (.E)
Stocks (F) (A+B+C) - (D+E+F)
Month Date
(A) Deliver (B) Other RHU (D)
(C)

Amlodipine 10mg, 30 0
tablets/treatment pack
Losartan 50mg, 30 0
tablets/treatment pack
Metoprolol 50mg,60 0
tablets/treatment pack
Metformin 500mg, 90 0
tablets/treatment pack
Stock Transfer
Ending Deliveries
(DM-2014-0317)
inventory
from the Quantity End of Month Stocks
DOH COMPLETE TREATMENT PREVIOUS Quantity Monthly Expired
PACK QTY Consumption (.E) (A+B+C) - (D+E+F)
Month Quantity Received QTY Transfer Stocks (F)
Date
Deliver (B) Other RHU (D)
(A) (C)

Amoxicillin 500mg, 21 0
capsule/ treatment pack
Amoxicillin 250mg/5mL, 0
60ml susp.
Co-Trimoxazole 800mg 0
tablet
Ciprofloxacin 500mg
tablet, 14 tablets per 0
treatment pack
Cloxacillin 500mg tablet,
14 tablets per treatment 0
pack

Cloxacillin 125mg/mL susp. 0

Doxycycline 100mg, 14
capsules per treatment 0
pack
Erythromycin 500mg, 21 0
tablets per treatment pack

Metronidazole 500mg, 21 0
tablets per treatment pack

Glibenclamide tablet 0
Gliclazide 30 tablets per 0
treatment pack

Simvastatin 20mg, 30 0
tablets per treatment pack

Aspirin 80mg, 30 tablets 0

per treatment pack

Enalapril 10mg tablets, 30 0

tablets per treatment pack

Salmeterol + Fluticasone 0
25/50 Inhaler

Salmeterol + Fluticasone 0
25/125 Inhaler

Salbutamol 100mcg 200 0

doses Inhaler
Lagundi 300mg, 15
capsules per treatment 0
pack

Sambong 250mg, 60 0
tablets per treatment pack

Prepared By: Noted By:

Signature over Printed Name Signature over Printed Name

Municipal Health Officer

Designation Designation