BALITE HEALTH CENTERBRGY. BALITE, RODRIGUEZ, RIZAL

IMMUNIZATION RECORDCHILD PROFILEF.N.: ________________NAME OF CHILD: _________________________________NAME OF MOTHER:_____________

DATE OF BIRTH: ________________________PLACE OF DELIVERY: ____________________

TIME OF BIRTH: _________________________TYPE OF DELIVERY: (C.S./NSD)

BIRTH WEIGHT: __________________ATTENDED BY: (MD/RN/RM/TBA/OTHER: ________)

NEW BORN SCREENING? (YES/NO) DATE: ___________TT STATUS: ____________

TYPE OF FEEDING: _____________________

GENDER: _______________________ADDRESS: ___________________________

IMMUNIZATIONSVACCINESDATE ADMINISTEREDSIGNATURE OF HEALTH PROF.DATE OF NEXT VISITREMARKS

B.C.G.

PENTA 1/OPV 1

PENTA 2/OPV 2

PENTA 3/OPV 3

HEP. B

AMV

MMR

OTHER:__________________

BALITE HEALTH CENTERBRGY. BALITE, RODRIGUEZ, RIZAL

IMMUNIZATION RECORDCHILD PROFILEF.N.: __________________NAME OF CHILD: _________________________________NAME OF MOTHER:_____________

DATE OF BIRTH: ________________________PLACE OF DELIVERY: ____________________

TIME OF BIRTH: _________________________TYPE OF DELIVERY: (C.S./NSD)

BIRTH WEIGHT: __________________ATTENDED BY: (MD/RN/RM/TBA/OTHER: _____)

NEW BORN SCREENING? (YES/NO) DATE: ___________T.T. STATUS: ____________

TYPE OF FEEDING: _____________________

GENDER: _______________________ADDRESS: ___________________________

IMMUNIZATIONSVACCINESDATE ADMINISTEREDSIGNATURE OF HEALTH PROF.DATE OF NEXT VISITREMARKS

B.C.G.

PENTA 1/OPV 1

PENTA 2/OPV 2

PENTA 3/OPV 3

HEP. B

AMV

MMR

OTHER:__________________

BALITE HEALTH CENTERBRGY. BALITE, RODRIGUEZ, RIZAL

PRENATAL/POSTPARTUM RECORDMATERNAL PROFILEF.N.: _______________NAME: ________________________________O.B. SCORE: G__P__ (T__P__A__L__)

AGE:_______________L.M.P. :_______________________

ADDRESS:______________________________E.D.C. :_______________________

FERROUS SULFATE: ____________________________________________________________

TETANUS TOXOID: 1__________ 2___________ 3___________ 4____________ 5___________

MATERNAL RECORDDATE OF VISITBPWTAOG( IN DAYS)FHTFH(cm)Lab ExamsU/A,CBC,HBSAgULTASOUNDINTERVENTIONS

POSTPARTUM PROFILEOUTCOME:BREASTFED? (YES/NO)

DATE OF DELIVERY:DATE OF INITIATION: _________________

TIME OF DELIVERY:

TYPE OF DELIVERY: ( NSD/CS)NEWBORN SCREENING? (YES/NO)

PLACE OF DELIVERY:DATE (REFERRED _______/DONE:________)

ATTENDED BY: (MD/RN/RM/TBA/OTHER: ______)GENDER OF CHILD: ________________

BIRTH WEIGHT OF CHILD: _____________

POSTPARTUM CHECK-UPS ( AFTER DELIVERY)VITAMIN A/ FeSO4 SUPPLEMENTATION

W/IN 24 HOURSW/IN 1 WEEKW/IN 24 HOURSW/IN 1 WEEK