10-10
MONTHLY REPORT 2 (front side)
Month__________________
Village:____________________________ Health worker_______________________
BIRTHS:
Name
Number of
brothers
Weight & sisters
Age of
mother
Named of Did you
midwife attend?
Any problems?
________________________ _______ _______ ______ _______ _______ ________________________
________________________ _______ _______ ______ _______ _______ ________________________
________________________ _______ _______ ______ _______ _______ ________________________
________________________ _______ _______ ______ _______ _______ ________________________
Did you give a ROAD TO HEALTH CHART to the mother of each newborn baby? YES____ NO___
DEATHS:
Name Age
Cause of death
_____________________ ______ _________________________________________________________
_____________________ ______ _________________________________________________________
_____________________ ______ _________________________________________________________
_____________________ ______ _________________________________________________________
PREVENTIVE MEDICINE:
Public sanitation
Number of latrines built this month__________ Homes with latrines_______ Homes without latrines______
Other activities_________________________________ Planned _______ In progress_______ Completed______
_______________________________ Planned _______ In progress ______ Completed______
Health education and activities
Times
What you did
Attendance
With mothers and under-fives _______ ______________________________________ _ __________
School-aged children................... _______ ______________________________________ _ __________
Other ........................................... _______ ______________________________________ _ __________
Family planning and prenatal care
Total
Number of women who started this month _____ Pill_ ____ Injections_____ IUD____ Ohter_ _______
Total number using birth control.................... _____ Pill_ ____ Injections_____ IUD____ Ohter_ _______
Number who stopped using birth control _____ Pill_ ____ Injections_____ IUD____ Ohter_ _______
Number planning who got pregnant.............______ Pill_ ____ Injections_____ IUD____ Other_ _______
Total number of pregnant women_ ________ Number receiving prenatal care this month________
Under-fives clinic AGE:
0 -1
1-2
2-3
3 - 4
4-5
Total number of children in the village................ _______ _______ ______ _ ______ _______
Number who have Road to Health charts........... _______ _______ ______ _ ______ _______
Number weighed this moth................................ _______ _______ ______ _ ______ _______
Number who were healthy................................. _______ _______ ______ _ ______ _______
Number who were ill.......................................... _______ _______ ______ _ ______ _______
Number with signs of malnutrition mild.............. _______ _______ ______ _ ______ _______
moderate _______ _______ ______ _ ______ _______
severe _______ _______ ______ _ ______ _______
Did you meet with the health committee this months?_______ With what results?_________________________
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