PREGNANT WOMEN

BARANGAY:___________________________________________
NAME OF CHT PARTNER:_________________________________

NAME AGE OUTCOME

 NEWBORN (0-29 DAYS)

BARANGAY:___________________________________________
NAME OF CHT PARTNER:_________________________________

NAME AGE BIRTHDAY

 UNDER FIVE CHILDREN (30 DAYS-BELOW 5 YRS OLD)

BARANGAY:___________________________________________
NAME OF CHT PARTNER:_________________________________

NAME AGE BIRTHDAY

 SENIOR CITIZENS

BARANGAY:___________________________________________
NAME OF CHT PARTNER:_________________________________

NAME AGE BIRTHDAY

 PERSONS WITH DISABILITY

BARANGAY:___________________________________________
NAME OF CHT PARTNER:_________________________________

NAME AGE TYPE OF DISABILITY

 FAMILY PLANNING

BARANGAY:___________________________________________
NAME OF CHT PARTNER:_________________________________

NAME AGE METHOD USED

 FAMILY WITH SANITARY TOILET

BARANGAY:___________________________________________
NAME OF CHT PARTNER:_________________________________

WITH SANITARY TOILET WITHOUT SANITARY TOILET

NAME OF HEAD OF THE FAMILY NAME OF HEAD OF THE FAMILY
 PATIENTS WITH TB

BARANGAY:___________________________________________
NAME OF CHT PARTNER:_________________________________

NAME AGE DATE STARTED TREATMENT

 PATIENTS WITH HIGH BLOOD

BARANGAY:___________________________________________
NAME OF CHT PARTNER:_________________________________

NAME AGE
 PATIENTS WITH DIABETES

BARANGAY:___________________________________________
NAME OF CHT PARTNER:_________________________________

NAME AGE
 CHT MEETING ATTENDANCE

DATE NAME BARANGAY SIGNATURE

CHT MEETING ATTENDANCE

DATE NAME BARANGAY SIGNATURE