| 9-1/0033 |
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REPUBLIC OF
NAMIBIA MINISTRY OF HEALTH AND SOCIAL SERVICES |
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| (Rev. 08/00) |
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Health Information System 2000 (HIS2K) |
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| FAMILY PLANNING / ANTENATAL CARE
/ POSTNATAL CARE MONTHLY SUMMARY REPORT FORM |
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| FACILITY
NAME: ______________________
REPORT FOR: MONTH: ______________ YEAR: _______ |
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| IF THIS
FORM IS FOR OUTREACH SERVICES ONLY,
TICK (3) HERE: ___ |
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| FAMILY
PLANNING |
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ANTENATAL CLINIC/CARE |
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| MALE
CLIENTS (1st Visit, Any age) |
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MOTHER'S AGE AT FIRST ANTENATAL VISIT |
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THIS PREGNANCY |
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| FEMALE
CLIENT: AGE AT TIME OF FIRST |
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| FAMILY
PLANNING VISIT |
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UNDER 15 YEARS OLD |
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15-19 YEARS OLD |
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| UNDER 15
YEARS OLD |
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20-24 YEARS OLD |
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25-29 YEARS OLD |
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| 15-19 YEARS
OLD |
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30-34 YEARS OLD |
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35 YEARS OLD AND OLDER |
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| 20-24 YEARS
OLD |
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| 25-29 YEARS
OLD |
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TRIMESTER OF PREGNANCY AT
FIRST |
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ANTENATAL VISIT THIS
PREGNANCY |
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| 30-34 YEARS
OLD |
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FIRST (0 -15 Weeks) |
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| 35 YEARS OLD
AND OLDER |
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SECOND (16 -28 Weeks) |
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THIRD (29 Or More Weeks) |
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| FEMALE
CLIENT: METHOD STARTED |
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| AT
FIRST VISIT |
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HAEMOGLOBIN AT FIRST ANTENATAL VISIT |
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| PILL |
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THIS PREGNANCY |
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| INJECTION |
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BELOW 10.0 G/DL |
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10.0 G/DL OR HIGHER |
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| IUCD |
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| MALE CONDOM |
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RPR TESTS DONE (Blood drawn or woman sent to lab) |
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| FEMALE
CONDOM |
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NUMBER
OF RPR TESTS |
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| ADVICE/COUNSELING
ONLY |
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RPR
TEST RESULTS |
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| FAMILY
PLANNING REVISIT |
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RPR POSITIVE |
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RPR NAGATIVE |
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| UNITS
OF FAMILY PLANNING |
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| COMMODITIES
DISTRIBUTED |
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TETANUS TOXOID (TT) |
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| PILL |
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PREVIOUSLY HAD/GIVEN TT2 |
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| INJECTION |
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TT2 AT REVISIT |
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| IUCD |
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ANTENATAL CARE REVISIT |
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| MALE CONDOM |
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| FEMALE
CONDOM |
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POSTNATAL CARE VISIT |
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| DEFAULTERS
THIS MONTH (for use only by |
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| facilities
using FP Card system) |
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| FORM
COMPLETED BY: NAME:
_________________ SIGNATURE:
___________________ DATE: _______ |
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| FORM
CHECKED BY: NAME: ____________________
SIGNATURE: ___________________
DATE: _______ |
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