REPUBLIC OF THE PHILIPPINES

PROVINCE OF ILOILO
MUNICIPALITY OF SAN JOAQUIN
MUNICIPAL HEALTH OFFICE Family Serial No:

INDIVIDUAL TREATMENT RECORD

NATIONAL IMMUNIZATION PROGRAM
NAME: AGE IN MONTH: MOTHER’S NAME:
ADDRESS: BW: FATHER’S NAME:
BIRTHDATE: HT/LENGTH: HUSBAND’S NAME:
PHIC: PLACE OF DELIVERY: TYPE OF DELIVERY:
NHTS (YES/NO): TIME OF DELIVERY: CONTACT NO.:

HEPA B (At Birth): _______________________ NBS: ______________________

DATE: AGE: ______________ DATE: AGE: ______________

WEIGHT: ___________ HT ____________ WEIGHT: ___________ HT ____________
NUTRITIONAL STATUS: ____________________ NUTRITIONAL STATUS: ____________________
PR: __________ RR: ____________ TEMP: PR: __________ RR: ____________ TEMP:

EXP. DOSE/ROUTE/ GIVEN EXP. DOSE/ROUTE/ GIVEN

VACCINE LOT NO. VACCINE LOT NO.
DATE SITE BY: DATE SITE BY:
0.5ml given IM 0.5ml given IM
PENTA ___ PENTA ___
@Right VL @Right VL
0.5ml given IM 0.5ml given IM
PCV___ PCV___
@Left VL @Left VL
2gtts given 2gtts given
OPV ___ OPV ___
orally orally
0.05ml given 0.5ml given IM
BCG___ IPV___
ID @ Right VL @ Left VL

INTERVENTIONS: INTERVENTIONS:
Give Paracetamol every 4hours for fever Give Paracetamol every 4hours for fever

REMARKS: REMARKS:

NEXT SCHEDULE: NEXT SCHEDULE:

DATE: AGE: ______________ DATE: AGE: ______________
WEIGHT: ___________ HT ____________ WEIGHT: ___________ HT ____________
NUTRITIONAL STATUS: ____________________ NUTRITIONAL STATUS: ____________________
PR: __________ RR: ____________ TEMP: PR: __________ RR: ____________ TEMP:

EXP. DOSE/ROUTE/ GIVEN EXP. DOSE/ROUTE/ GIVEN

VACCINE LOT NO. VACCINE LOT NO.
DATE SITE BY: DATE SITE BY:
0.5ml given IM 0.5ml given IM
PENTA ___ MCV__
@Right VL @ Left VL
0.5ml given IM 0.5ml given IM
PCV___ IPV___
@Left VL @ Left VL
2gtts given
OPV ___
orally

INTERVENTIONS: INTERVENTIONS:
Give Paracetamol every 4hours for fever Give Paracetamol every 4hours for fever

REMARKS: REMARKS:

NEXT SCHEDULE: NEXT SCHEDULE:

DATE: AGE: ______________ DATE: AGE: ______________
WEIGHT: ___________ HT ____________ WEIGHT: ___________ HT ____________
NUTRITIONAL STATUS: ____________________ NUTRITIONAL STATUS: ____________________
PR: __________ RR: ____________ TEMP: PR: __________ RR: ____________ TEMP:
FIC EXP. DOSE/ROUTE/ GIVEN EXP. DOSE/ROUTE/ GIVEN
VACCINE LOT NO. VACCINE LOT NO.
DATE SITE BY: DATE SITE BY:
0.5ml given IM
MCV___
@ Left VL

INTERVENTIONS: INTERVENTIONS:
Give Paracetamol every 4hours for fever

REMARKS: REMARKS:

NEXT SCHEDULE: NEXT SCHEDULE:

DATE: AGE: ______________ DATE: AGE: ______________

WEIGHT: ___________ HT ____________ WEIGHT: ___________ HT ____________
NUTRITIONAL STATUS: ____________________ NUTRITIONAL STATUS: ____________________
PR: __________ RR: ____________ TEMP: PR: __________ RR: ____________ TEMP:

EXP. DOSE/ROUTE/ GIVEN EXP. DOSE/ROUTE/ GIVEN

VACCINE LOT NO. VACCINE LOT NO.
DATE SITE BY: DATE SITE BY:

INTERVENTIONS: INTERVENTIONS:

REMARKS: REMARKS:

NEXT SCHEDULE: NEXT SCHEDULE: