Call Sheet
SUMMARY CALL SHEET
For the Month of:__________ Year:____________ Name of CHT Member (Last Name, First Name) Coverage Purok/Barangay Name of Midwife (Last Name, First Name)
_________________________________________________ ______________________________________ _____________________________________ NHTS HOUSEHOLD ID NO./SURNAME | Family Data | Prenatal Checkup | Iron with Folic Acid supp. | Tetanus toxoid | Facilioty based delivery | Postpartum Checkup | Newborn Screening | Immunization | Child | Modern FP | ChronicCoughCheckup,SputumExam,Treatment | Others | | 4p | Located/Visited | With PhilHealth card | With Philheakth Plans | | | | | | | Hepa B | BCG | OPV | DPT | MEASLES | Deworming | Vit. A Supp. | FP Couns. | NFP | Pills | DMPA | Condom | IUD | Vasectomy | Ligation | | | | Y/N | L/V | Y/N | Y/N | 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 1-P, 1-G) | BHS GANGAHIN | 466 | V | Y | Y | 33-G | 32-G | 25-G | 4-G | 14-G | 0 | 61-G | 61-G | 61-G | 61-G | 26-G | 0 | 26-G | 219-G | 105-G | 67-G | 12-G | 4-G | 7-G | 0 | 1-G | 5-G | 102-G | BHS SAMPALOC | 308 | V | Y | Y | 17-G | 14-G | 13-G | 3-G | 3-G | 0 | 21-G | 8-G | 21-G | 24-G | 14-G | 0 | 14-G | 42-G | 0 | 12-G | 1-G | 0 | 0 | 0 | 0 | 1-G | 87-G | BHS POCTOL | 281 | V | Y | Y | 9-G | 9-G | 5-G | 0 | 4-G | 0 | 21-G | 4-G | 17-G | 17-G | 9-G | 0 | 7-G | 0 | 2-G | 27-G | 17-G | 0 | 4-G | 0 | 6-G | 0 | 22-G | BHS POBLACION | 281 | V | Y | Y | 14-G | 10-G | 6-G | 1-G | 1-G | 0 | 12-G | 1-G | 6-G | 7-G | 3-G | 0 | 3-G | 42-G | 53-G | 22-G | 6-G | 1-G | 12-G | 0 | 13-G | 4-G | 287-G | | | | | | | | | | | | | | | | | | | | | | | | | | | | | Total No. of Members | | | | | | | | | | | | | | | | |
For the Month of:__________ Year:____________ Name of CHT Member (Last Name, First Name) Coverage Purok/Barangay Name of Midwife (Last Name, First Name)
_________________________________________________ ______________________________________ _____________________________________ NHTS HOUSEHOLD ID NO./SURNAME | Family Data | Prenatal Checkup | Iron with Folic Acid supp. | Tetanus toxoid | Facilioty based delivery | Postpartum Checkup | Newborn Screening | Immunization | Child | Modern FP | ChronicCoughCheckup,SputumExam,Treatment | Others | | 4p | Located/Visited | With PhilHealth card | With Philheakth Plans | | | | | | | Hepa B | BCG | OPV | DPT | MEASLES | Deworming | Vit. A Supp. | FP Couns. | NFP | Pills | DMPA | Condom | IUD | Vasectomy | Ligation | | | | Y/N | L/V | Y/N | Y/N | 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 1-P, 1-G) | BHS GANGAHIN | 466 | V | Y | Y | 33-G | 32-G | 25-G | 4-G | 14-G | 0 | 61-G | 61-G | 61-G | 61-G | 26-G | 0 | 26-G | 219-G | 105-G | 67-G | 12-G | 4-G | 7-G | 0 | 1-G | 5-G | 102-G | BHS SAMPALOC | 308 | V | Y | Y | 17-G | 14-G | 13-G | 3-G | 3-G | 0 | 21-G | 8-G | 21-G | 24-G | 14-G | 0 | 14-G | 42-G | 0 | 12-G | 1-G | 0 | 0 | 0 | 0 | 1-G | 87-G | BHS POCTOL | 281 | V | Y | Y | 9-G | 9-G | 5-G | 0 | 4-G | 0 | 21-G | 4-G | 17-G | 17-G | 9-G | 0 | 7-G | 0 | 2-G | 27-G | 17-G | 0 | 4-G | 0 | 6-G | 0 | 22-G | BHS POBLACION | 281 | V | Y | Y | 14-G | 10-G | 6-G | 1-G | 1-G | 0 | 12-G | 1-G | 6-G | 7-G | 3-G | 0 | 3-G | 42-G | 53-G | 22-G | 6-G | 1-G | 12-G | 0 | 13-G | 4-G | 287-G | | | | | | | | | | | | | | | | | | | | | | | | | | | | | Total No. of Members | | | | | | | | | | | | | | | | |