HSCMDA Barangay Master List and Recording Form

(Schistosomiasis Community Based Mass Drug Administration)

Region: Province: Municipality:

NO. SURNAME GIVEN NAME MIDDLE NAME SEX AGE IN YEARS DATE OF BIRTH PUROK # OF DRUGS GIVEN DATE GIVEN
1 Humont Palma D F 29 8/15/1987 P. Ats 4 1/2 6/27/2017
2 Labiano Juraida A F 69 6/15/1981 P. Ats 4 6/27/2017
3 Berwal Michael N M 35 6/15/1981 P. Sweet Lady 4 1/2 6/27/2017
4 Abas Norshia C F 29 6/30/1987 P. Bayabasan 5 6/27/2017
5 Abas Mursidin E M 42 5/9/1975 P. Bayabasan 3 3/4 6/27/2017
6 Ismael Bendang B F 62 8/14/1955 P. Bayabasan 3 1/2 6/27/2017
7 Punto Judith F F 41 6/8/1976 P. Bayabasan 3 1/2 6/27/2017
8 Punto Ampad S M 51 7/8/1966 P. Bayabasan 3 1/2 6/27/2017
9 Punto Adnier W M 16 7/10/2001 P. Bayabasan 2 1/2 6/27/2017
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Barangay:

ADVERSED EFFECT REMARKS(HT.(CM)/WT.(KGS)/BP)

wt: 63 kg , ht: 154cm, BP: 120/80
wt: 60kg, ht: 152cm, BP: 130/90
wt: 63kg, ht: 164cm, BP: 140/80
wt: 72kg, ht: 156cm, BP: 130/80
wt: 53 kg, ht: 165cm, BP: 120/80
wt: 50kg, ht: 156cm, BP: 120/80
wt: 50kg, ht: 156cm, BP: 120/80
wt: 50 kg, ht: 155cm, BP: 130/80
wt: 35 kg, ht: 154cm, BP: 110/90