NEW m1m2 Reporting Form
NEW m1m2 Reporting Form
NEW m1m2 Reporting Form
BRGY
Projected Population of the Year:
c. Condom - Total
d. Pills - Total
f. Implant - Total
h. NFP-LAM - Total
i. NFP-BBT - Total
j. NFP-CMM - Total
k. NFP-STM - Total
l. NFP-SDM - Total
7. No. of pregnant women given iodine 20a. No. of live births with normal birth
capsules - Total weight - Total
8. No. of pregnant women given one 20b. No. of live births with low birth
dose of deworming tablet - Total weight - Total
9. No. of pregnant women screened for 20c. No. of live births with unknown
syphilis - Total birth weight - Total
23. Preterm/LBW infants given iron 28. Infants 6-11 mos. old seen - Total 33. Children 12-23 mos. seen - Total
supplementation - Total
24. Infants 6 mos. old seen - Total 29. Infants 6-11 mos. given 1 dose of 34. Children 12-23 mos. who completed
Vitamin A 100,000 I.U. - Total MNP supplementation - Total
25. Infants exclusively breastfed until 30. Children 12-59 mos seen - Total
6th month - Total
26. Infants 6 mos. old initiated to 31. Children 12-59 mos. old given 2
complementary feeding with doses of Vitamin A 200,000 I.U. -
continued breastfeeding - Total Total
C3. Deworming Services
37. SAC, 5-9 y/o dewormed (2 doses)
35. 1-19 y/o given 2 doses of deworming drug - Total
- Total
38. Adolescents, 10-19 y/o dewormed
36. PSAC, 1-4 y/o dewormed (2 doses) - Total
(2 doses) - Total
C4. Management of Sick Infants and Children
42. Sick Children 12-59 mos. old 45. Diarrhea cases 0-59 mos. received
39. Sick Infants 6-11 mos. old seen - Total
received Vitamin A - Total ORS w/ zinc - Total
40. Sick Infants 6-11 mos. old received 43. Diarrhea cases 0-59 months old 46. Pneumonia cases 0-59 mos. old
Vitamin A - Total seen - Total seen - Total
44. Diarrhea cases 0-59 months old 47. Pneumonia cases 0-59 mos. old
41. Sick Children 12-59 mos. old seen - Total
received ORS - Total completed treatment - Total
Section D. Oral Care and Services
To be submitted Quarterly
Section E. Infectious Disease Prevention and Control Services
Indicators Male Female Total Indicators Male Female Total Indicators Male Female Total
(Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3) (Col 4) (Col. 1) (Col 2) (Col 3) (Col 4)
E1. Filariasis Prevention and Control (to be reported annually)
E2. Schistosomiasis Prevention and Control
7. No. of confirmed cases (acute and
1. No. of patients seen - Total 4. No. of confirmed acute cases - Total
chronic) - Total
5. No. of chronic clinically diagnosed
2. No. of suspected cases seen 8. No. of cases treated - Total
cases - Total
9. No. of confirmed chronic cases
3. No. acute clinically diagnosed cases - Total 6. No. confirmed chronic cases - Total
referred to a hospital facility - Total
E3. Soil Transmitted Helminthiasis Prevention and Control (reflected under Child Care, Family Planning and Maternal Care)
FHSIS ver. 2018 M1-HPA | Page 7 of 24
E4. HIV-AIDS/STI Prevention and Control (reflected under Maternal Care)
4. Overweight/Obese - Total 8. No. of adult women with suspicious 13. No. of senior citizens who received
breast mass - Total one (1) dose of PPV - Total
Cholera A00.0-A00.9
A09.0
Acute Watery Diarrhea
(watery)
A09.0
Acute Bloody Diarrhea
(bloody)
Typhoid and Paratyphoid Fever A01.1-A01.4
Leptospirosis A27.0-A27.9
Leprosy A30.0-A30.9
Diphtheria A36.0-A36.9
Meningococcemia A39.2-A39.4
Syphilis A50-A53
Gonorrhea A54.0-A54.9
Malaria B50-B54
Schistosomiasis B65.0-B65.9
Filariasis B74.0-B74.9
Pneumonia J18.90-J18.99
Other Diseases
Chickenpox B01.89
Chronic Obstructive Pulmonary
J44.0-J44.9
Disease (COPD)
Hypertension I10.0-I10.9
Skin Diseases
Tuberculosis, Respiratory
Whooping Cough
I00-I09, I11,
Diseases of the Heart
I13, I20-I51
M2
Name of Health Facility:
Name of Barangay:
Name of Municipality/City:
Name of Province:
Projected Population of the Year:
2.
3.
4.
5.
6.
7.
8.
9.
10.
Section A.2.b Ten Leading Causes of Morbidity in Males
Name of Disease Number of Cases Rate per 100,000 population
No.
(Col. 1.) (Col. 3) (Col. 4)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Section A.2.c Ten Leading Causes of Morbidity in Females
Name of Disease Number of Cases Rate per 100,000 population
No.
(Col. 1.) (Col. 3) (Col. 4)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Section A.2.d Ten Leading Causes of Morbidity in Under-Five Children
Name of Disease Number of Cases Rate per 100,000 population
No.
(Col. 1.) (Col. 3) (Col. 4)
1.
2.
3.
4.
5.
6.
7.
8.
M2
Name of Health Facility:
Name of Barangay:
Name of Municipality/City:
Name of Province:
Projected Population of the Year:
9.
10.
M2
Name of Health Facility:
Name of Barangay:
Name of Municipality/City:
Name of Province:
Projected Population of the Year:
Section A.2.e Ten Leading Causes of Morbidity in Adolescents 10-19 Years Old
Name of Disease Number of Cases Rate per 100,000 population
No.
(Col. 1.) (Col. 3) (Col. 4)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Section A.2.f Ten Leading Causes of Morbidity in Senior Citizens ≥ 60 years old
Name of Disease Number of Cases Rate per 100,000 population
No.
(Col. 1.) (Col. 3) (Col. 4)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Section A.2.g Ten Leading Causes of Morbidity in Pregnant Women
Name of Disease Number of Cases Rate per 100,000 population
No.
(Col. 1.) (Col. 3) (Col. 4)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
M2
Name of Health Facility:
Name of Barangay:
Name of Municipality/City:
Name of Province:
Projected Population of the Year: