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NAME: ____________________________________________________________________ 4PS/MCCT: ________________________

(LAST NAME) (FIRST NAME) (MIDDLE NAME) NHTS NUMBER: ____________________


AGE: ________ SEX: _________
BIRTHDAY: ____________________
BRGY: _________________________ ZONE: ________

BLOOD
WEIGHT HEIGHT LMP EDC FAMILY PLANNING
DATE PRESSURE (FOR HRU) REMARKS
(kg) (cm) (FOR HRU) (FOR PREGNANT)
(10 y.o. & above)

January ____ 2019

February ____ 2019

March ____ 2019

April ____ 2019

May ____ 2019

June ____ 2019

July ____ 2019

August ____ 2019

September ____ 2019

October ____ 2019

November ____ 2019

December ____ 2019