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Exercise 4 - M1 Blank Form

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Mho Alcala
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124 views1 page

Exercise 4 - M1 Blank Form

Uploaded by

Mho Alcala
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as XLSX, PDF, TXT or read online on Scribd
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M1

FHSIS REPORT for the MONTH: DECEMBER YEAR: 2019


Name of Barangay: SAMPAGUITA
Name of Clinic: Clinic A
Name of Municipality/City: _______________________________

Lying In
Name of Province: _______________________________
Projected Population of the Year: _______________________________
For submission to RHU/MHC

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 20-49 10-14 15-19 20-49 10-14 15-19 20-49 10-14 15-19 20-49 10-14 15-19 20-49 10-14 15-19 20-49
Total Total Total Total Total Total
y/o y/o y/o y/o y/o y/o y/o y/o y/o y/o y/o y/o y/o y/o y/o y/o y/o y/o

a. BTL - Total

b. NSV - Total

c. Condom - Total

d.1 Pills-POP - Total

d.2 Pills-COC - Total

e. Injectables (DMPA/POI)-Total

f. Implant - Total

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

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