PHILIPPINE HEALTH AGENDA - FIRST 100 DAYS

WEEKLY TSEKAP REPORT

Region PERIOD COVERED
Province MM/DAY/2016 FORM 2 - WEEKLY REPORTING
Municipality/City TO FORM
No.of Household Profiled MM/DD/2016

NEWBORN INFANT CHILD ADOLESCENT

60 YRS AND
20-49 yrs old 50-59 yrs old SUBTOTAL GRAND
0-28 days 29 days- 11mos 1-5 yrs old 6-9 yrs old 10-19 yrs old ABOVE
BASIC HEALTH SERVICES
TOTAL
F F
M F M F M F M F M M M F M F M F
Pregnant Post Partum Non-Pregnant Pregnant Post Partum Non-Pregnant
NUMBER OF PATIENTS ASSESSED

PHYSICAL EXAMINATION
Blood Pressure
Weight Measurement
Obese
Undernutrition
Height Measurement
Stunted
LABORATORY EXAMINATION
Blood Typing
Complete Blood Count
Urinalysis
Fasting Blood Sugar
Stool Examination
FAMILY PLANNING SERVICES
Counseling
Commodities
HEALTH EDUCATION AND PROMOTION SERVICES
OTHER SERVICES
Eye Exam
Ear Exam
Oral Services
SUBTOTAL

GRAND TOTAL

TOTAL NO. OF CLIENTS PROVIDED WITH AT LEAST 3

SERVICES (BASED ON FORM 1A-1H)

CASES REFERRED (specify)

1
2
3
4
.
TOTAL CASES REFERRED

DRUG REHABILITATION SERVICES

Screening
Counseling
Drug Testing
Referral
TOTAL DRUG REHABILITATION SERVICES