NAME OF BARANGAY/RHU:

MUNICIPALITY OF:

PROVINCE/CITY:

REGION:
 FHSIS v. 2012
TARGET CLIENT LIST FOR PRENATAL CARE
TCL-PN
DATE OFFAMILY D A T
REGIS- SERIAL LMP EDC PRENATAL
NAME ADDRESS AGE
TRATION NO. mm/dd/yy (mm/dd/yy) (8)
mm/dd/yy G-P FIRST
(1) (2) (3) (4) (5) (6) (7) TRIMESTER

NOTE: First Trimester = the first 3 months (up to 12 weeks or 0-84 day
Second Trimester = the middle 3 months (13-27 weeks or 85-18
Third Trimester = the last 3 months (28 weeks and more or 190 d

15
 D A T E
PRENATAL VISITS
(8)
SECOND THIRD
TRIMESTER TRIMESTER

weeks or 0-84 days)

27 weeks or 85-189 days)
and more or 190 days and more)

16
17
 TARGET CLIENT LIST FOR PRENATAL CARE
DATE TETANUS TOXOID VACCINE MICRONUTRIENT SUPPLEMENTATION STI SURVEILLANCE PREGNANCY LIVEBIRTHS
TETANUS GIVEN (11) (12) (13) (14)
STATUS BIRTH PLACE OF
(10) DATE & NUMBER
TESTED RESULT FOR GIVEN OUT- DELIVERY
FOR SY SY TESTING PENICILLIN DATE
(9) IRON W/ FOLIC ACID COME*/G WEIGHT
TERMI- Health
ender NID
Y/N NATED
TT1 TT2 TT3 TT4 TT5 WAS GIVEN DATE (+/-) / DATE (M/F) (grams) Facility**
Date

*Outcome: **Health Code: ***Attended by:

LB = Livebirth Facility or RHU
FD = Fetal Death Non- BeMONC
 AB = Abortion Institution CeMONC
Delivery Hospital
(NID) Lying-in clinics
This refers to deliveries by place:
Health facility: Hospitals, RHUs, lying-ins/birthing homes (including BEMOC, CEMO
Non-institutional delivery (NID) includes: home, in-transit and others.
HS

REMARKS

ATTENDED
BY***
(15)

tended by:
MD = Doctor
RN = Nurse
 RM= Midwife
H = Hilot/TBA
O = Others

BEMOC, CEMOC)
hers.
FHSIS TARGET CLIENT LIST FOR PRENATAL CARE

DATE OF FAMILY D A T
REGIS- SERIAL LMP EDC PRENATAL
NAME ADDRESS AGE
TRATION NO. mm/dd/yy (mm/dd/yy) (8)
mm/dd/yy G-P FIRST

(1) (2) (3) (4) (5) (6) (7) TRIMESTER

 FHSIS TARGET CLIENT LIST FOR PRENATAL CARE

D A T E DATE TETANUS TOXOID VACCINE MICRONUTRIENT SUPPLEMENTATION STI SURVEILLANCE PREGNANCY

PRENATAL VISITS TETANUS GIVEN (11) (12) (13)
(8) STATUS (10) DATE & NUMBER TESTED RESULT FOR GIVEN
FOR SY SY TESTING PENICILLIN DATE
SECOND THIRD (9) IRON W/ FOLIC ACID
TERMI-
Y/N NATED
TRIMESTER TRIMESTER TT1 TT2 TT3 TT4 TT5 WAS GIVEN DATE (+/-) / DATE
Date
FHSIS TARGET CLIENT LIST FOR PRENATAL CARE

PREGNANCY LIVEBIRTHS
(13) (14)
PLACE OF REMARKS
OUT- BIRTH
DELIVERY
COME*/G WEIGHT ATTENDED
ender Health BY***
NID
(M/F) (grams) Facility**
(15)