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National Safe Motherhood Program: (Date) (Date) (Place A Check) (LN, FN, MI) (Date)

The document is a form for tracking pregnancies through the National Safe Motherhood Program. It collects information such as the name, age, expected due date, antenatal check-ups, pregnancy outcome, and civil registration of pregnant women. The form also tracks the birthing center used and includes spaces for referrals and signatures of community health workers involved in the program.

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Wilma Beralde
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3K views1 page

National Safe Motherhood Program: (Date) (Date) (Place A Check) (LN, FN, MI) (Date)

The document is a form for tracking pregnancies through the National Safe Motherhood Program. It collects information such as the name, age, expected due date, antenatal check-ups, pregnancy outcome, and civil registration of pregnant women. The form also tracks the birthing center used and includes spaces for referrals and signatures of community health workers involved in the program.

Uploaded by

Wilma Beralde
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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National Safe Motherhood Program

PREGNANCY TRACKING

Year: ____________________________ Birthing Center: ____________________________


Region: ____________________________ Address: ____________________________
Province: ____________________________ Referral Center: ____________________________
Municipality: ____________________________ Address: ____________________________
Barangay: ____________________________

No. Name Age Gravidity Parity Expected Date of Antenatal Care Check-Ups Pregnancy Outcome Mother and Child Civil Registration
(LN, FN, MI) Delivery (Date) (Place a check) Postnatal Check-ups (Date)
(Date)
1st tri = up 2nd tri = 3rd tri = 28 weeks AOG Live birth Preterm Stillbirth Abortion Day of Within 7 Livebirth Maternal Stillbirth Early
to 12 weeks 13-27 weeks and more Birth Discharge/ days after Death Newborn
and 6 days and 6 days 24 hours birth Death
AOG AOG after birth (0-7 days)
1

10

Name of BHW: _________________________ Barangay Health Station: _________________________


Name of Midwife: _________________________ Rural Health Unit: _________________________

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