PHILIPPINE HEALTH AGENDA

WEEKLY TSEKAP REPORT FORM 2 - WEEKLY REPORTING

REGION VIII PERIOD COVERED FORM
PROVINCE SAMAR
MUNICIPALITY/CITY HINABANGAN (BHS Yabon) MAY 9-15, 2018

NO. OF HOUSEHOLD PROFILED

NEWBORN INFANT CHILD ADOLESCENT
20 to 49 yrs old 50 to 59 yrs old 60 yrs & above SUBTOTAL
0 - 28 DAYS 29 DAYS - 11 MONS 1 to 4 yrs old 5 to 9 yrs old 10 - 19 yrs old GRAND
BASIC HEALTH SERVICES
TOTAL
M F M F M F M F M F M F M F M F M F
PREG POST-PAR NONPREG PREG POST-PAR NONPREG

NUMBER OF PATIENTS ASSESSED 0 0 0

PHYSICAL EXAMINATION 0 0 0
Blood Pressure 0 0 0
Weight Measurement 0 0 0
Obese 0 0 0
Undernutrition 0 0 0
Height Measurement 0 0 0
Stunted 0 0 0
0 LABORATORY EXAMINATION
Blood Typing 0 0 0
Complete Blood Count 0 0 0
Urinalysis 0 0 0
0 Fasting Blood Sugar 0 0 0
Stool Examination 0 0 0
FAMILY PLANNING SERVICES
Counseling 0 0 0
Commodities 0 0 0
HEALTH EDUCATION AND PROMOTION SERVICES 0 0 0
OTHER SERVICES 0 0 0
Eye Exam 0 0 0
Ear Exam 0 0 0
Oral Services 0 0 0
SUBTOTAL
GRAND TOTAL

TOTAL NUMBER OF CLIENTS PROVIDED WITH AT

LEAST 3 SERVICES (Based on Form 1A-1H)
Cases Referred (specify)
1
2
3
4
….
TOTAL CASES REFERRED
DRUG REBAHILITATION SERVICES
Screening
Counseling
Drug Testing
Referral
TOTAL DRUG REHABILITATION SERVICES

Noted by:
PHILIPPINE HEALTH AGENDA
RECORDING FORM

PHYSICAL
SEX WEIGHT HEIGHT
# NAME EXAM
M/F DATE kg cm
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
 82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100
 COMPLETE BLOOD STOOL EYE EAR ORAL
URINALYSIS
BLOOD COUNT TYPING EXAM EXAM EXAM SERVICES
Y/N Y/N Y/N Y/N Y/N Y/N Y/N
 FORM
1B
NEWBORN 0 - 28 DAYS

SIGNIFICANT FINDINGS REMARKS/ACTIONS TAKEN

PHILIPPINE HEALTH AGENDA - 100 DAYS FORM
RECORDING FORM 1
Household Profile
Date Visited/Profiled:
NHTS No.
Province
Municipality/City
Barangay
Name of NHTS Member and Dependents Relation Birthday Age Sex Philhealth Member Remarks
(Last, First, Middle Name) M/F Y/N (Philhealth no., etc)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
PHILIPPINE HEALTH AGENDA - FIRST 100 DAYS
RECORDING FORM

Sex Physical Exam Weight Length

# Name
M/F Y/N kg cm
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
 82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100
 FORM
1A
NEWBORN 0 - 28 DAYS
Eye Exam Ear Exam
Significant Findings Remarks/Actions Taken
Y/N Y/N
PHILIPPINE HEALTH AGENDA
RECORDING FORM

PHYSICAL
SEX WEIGHT HEIGHT
# NAME EXAM
M/F DATE kg cm
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
 82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100
 COMPLETE BLOOD STOOL EYE EAR ORAL
URINALYSIS
BLOOD COUNT TYPING EXAM EXAM EXAM SERVICES
Y/N Y/N Y/N Y/N Y/N Y/N Y/N
 FORM
1C
CHILD (1-4 years old)

SIGNIFICANT FINDINGS REMARKS/ACTIONS TAKEN

PHILIPPINE HEALTH AGENDA
RECORDING FORM

PHYSICAL
SEX WEIGHT HEIGHT
# NAME EXAM
M/F DATE kg cm
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
 82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100
 COMPLETE BLOOD STOOL EYE EAR ORAL
URINALYSIS
BLOOD COUNT TYPING EXAM EXAM EXAM SERVICES
Y/N Y/N Y/N Y/N Y/N Y/N Y/N
/

/
 FORM
1D
CHILD (5-9 years old)

SIGNIFICANT FINDINGS REMARKS/ACTIONS TAKEN

PHILIPPINE HEALTH AGENDA - FIRST 100 DAYS
RECORDING FORM

F
# Name M post non
pregnant
partum pregnant
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100
 BLOOD BLOOD
PHYSICAL EXAM WEIGHT HEIGHT CBC
PRESSURE TYPING
DATE kg cm Y/N Y/N Y/N
 FASTING STOOL FAMILY PLANNING EYE
URINALYSIS
BLOOD SUGAR EXAM w/ unmet EXAM
counseling commodities
Y/N Y/N Y/N need DATE
/

/
/
 FORM
1E
10 - 19 years old
EAR ORAL
EXAM EXAM SIGNIFICANT FINDINGS REMARKS/ACTIONS TAKEN
DATE DATE
PHILIPPINE HEALTH AGENDA
RECORDING FORM

PHYSICAL
SEX WEIGHT HEIGHT
# NAME EXAM
M/F DATE kg cm
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100
 COMPLETE BLOOD STOOL EYE EAR ORAL
URINALYSIS
BLOOD COUNT TYPING EXAM EXAM EXAM SERVICES
Y/N Y/N Y/N Y/N Y/N Y/N Y/N
 FORM
1E
MEN (10-19 years old)

DRUG REHABILITATION
SIGNIFICANT FINDINGS REMARKS/ACTIONS TAKEN
Y/N
PHILIPPINE HEALTH AGENDA - FIRST 100 DAYS
RECORDING FORM

F
# Name M post non
pregnant
partum pregnant
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100
 BLOOD BLOOD
PHYSICAL EXAM WEIGHT HEIGHT CBC URINALYSIS
PRESSURE TYPING
DATE kg cm Y/N Y/N Y/N Y/N
 FASTING STOOL FAMILY PLANNING EYE EAR ORAL
BLOOD SUGAR EXAM w/ unmet EXAM EXAM EXAM
counseling commodities
Y/N Y/N need Y/N Y/N Y/N
 FORM
1F
20 - 49 years old

SIGNIFICANT FINDINGS REMARKS/ACTIONS TAKEN

PHILIPPINE HEALTH AGENDA
RECORDING FORM

PHYSICAL BLOOD
SEX WEIGHT HEIGHT
# NAME EXAM PRESSUE
M/F DATE kg cm Y/N
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100
 COMPLETE BLOOD STOOL EYE EAR ORAL
URINALYSIS
BLOOD COUNT TYPING EXAM EXAM EXAM SERVICES
Y/N Y/N Y/N Y/N Y/N Y/N Y/N
 FORM
1G
50 - 59 years old

SIGNIFICANT FINDINGS REMARKS/ACTIONS TAKEN

PHILIPPINE HEALTH AGENDA
RECORDING FORM

PHYSICAL BLOOD
SEX WEIGHT HEIGHT
# NAME EXAM PRESSUE
M/F DATE kg cm Y/N
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100
 COMPLETE BLOOD STOOL EYE EAR ORAL
URINALYSIS
BLOOD COUNT TYPING EXAM EXAM EXAM SERVICES
Y/N Y/N Y/N Y/N Y/N Y/N Y/N
 FORM
1H
60 years and above

SIGNIFICANT FINDINGS REMARKS/ACTIONS TAKEN