Month of : Name of CHT Member:

Prenatal Checkup

MAKATI HEALTH DEPARTMENT COMMUNIT HEALTH TEAM MOBILIZATION SUMMARY CALL SHEET REPORT Barangay : Team leader: Tetanus Toxoid FAMILY DATA
WITH HEALTH PLANS GIVEN W/ PHILHEALTH

Iron with Folic Acid Supp.

Immunization Facility-based Delivery Postpartum Checkup

Newborn Screening

vitamin A for adult

Child Deworming Vit. A Supp. FP Couns.

Modern FP Vasectomy
Chronic Cough Checkup, Treatment

Condom

VISITED

4P

1 bar for every individual using the health service; write P if the service is obtained from a private facility and G if from a government facility (e.g. I-P, I-G)

Ligation

Hepa B

Fe So4

DMPA

OPV

BCG

DPT

NFP

Pills

IUD

NHTS HOUSEHOLD ID NO./SURNAME

MEASLES

Others, Please specify

Put NHTS ID Number & HH Head

Y/N

PUT 1-G ; 1-P ; 2-G; 2-P ;3-P; 3-G and so on (G-Government; P-Rivate ; Number - Number of Individual)

Specify service