M O N T H LY R E P O RT 2 ( b a ck s i d e )
HEALTH PROBLEMS SEEN THIS MONTH
10-11
AGE:
Colds and flu ___ ___ ___ ____ ___ ___ ___ ______ _______ _________
Pneumonia ___ ___ ___ ____ ___ ___ ___ ______ _______ _________
Other respiratory problem ___ ___ ___ ____ ___ ___ ___ ______ _______ _________
____________________ ___ ___ ___ ____ ___ ___ ___ ______ _______ _________
Diarrhea and dysentery ___ ___ ___ ____ ___ ___ ___ ______ _______ _________
Dehydration ___ ___ ___ ____ ___ ___ ___ ______ _______ _________
Vomiting ___ ___ ___ ____ ___ ___ ___ ______ _______ _________
Urinary problems_______ ___ ___ ___ ____ ___ ___ ___ ______ _______ _________
____________________ ___ ___ ___ ____ ___ ___ ___ ______ _______ _________
Roundworm ____ ___ ___ ____ ___ ___ ___ ______ _______ _________
Other parasites_________ ___ ___ ___ ____ ___ ___ ___ ______ _______ _________
___________________ ___ ___ ___ ____ ___ ___ ___ ______ _______ _________
Gastritis or ulcer ___ ___ ___ ____ ___ ___ ___ ______ _______ _________
Other belly problem ___ ___ ___ ____ ___ ___ ___ ______ _______ _________
________________________ ___ ___ ____ ___ ___ ___ ______ _______ _________
Malnutrition ___ ___ ___ ____ ___ ___ ___ ______ _______ _________
Anemia ___ ___ ___ ____ ___ ___ ___ ______ _______ _________
Skin problems__________ ___ ___ ___ ____ ___ ___ ___ ______ _______ _________
____________________ ___ ___ ___ ____ ___ ___ ___ ______ _______ _________
____________________ ___ ___ ___ ____ ___ ___ ___ ______ _______ _________
Accidents: wounds
___ ___ ___ ____ ___ ___ ___ ______ _______ _________
fractures ___ ___ ___ ____ ___ ___ ___ ______ _______ _________
Other__________________ ___ ___ ___ ____ ___ ___ ___ ______ _______ _________
Measle
Mumps
____ ___ ___ ____ ___ ___ ___ ______ _______ _________
____ ___ ___ ____ ___ ___ ___ ______ _______ _________
Whooping cough
____ ___ ___ ____ ___ ___ ___ ______ _______ _________
Malaria ____ ___ ___ ____ ___ ___ ___ ______ _______ _________
Tuberculosis ____ ___ ___ ____ ___ ___ ___ ______ _______ _________
Leprosy ____ ___ ___ ____ ___ ___ ___ ______ _______ _________
Rabies ____ ___ ___ ____ ___ ___ ___ ______ _______ _________
Other problems________ ___ ___ ___ ____ ___ ___ ___ ______ _______ _________
____________________ ___ ___ ___ ____ ___ ___ ___ ______ _______ _________
____________________ ___ ___ ___ ____ ___ ___ ___ ______ _______ _________
??
Could not figure out
___ ___ ___ ____ ___ ___ ___ ______ _______ _________
____________________ ___ ___ ___ ____ ___ ___ ___ ______ _______ _________
TOTAL PROBLEMS SEEN ___ ___ ___ ____ ___ ___ ___ ______ _______ _________
*The heading “gave no medicine” is included to encourage health workers not to give medicine for
every problem.