TARGET CLIENT LIST FOR FAMILY PLANNING

DMPA (INJECTIBLES)
PUT A NAME OF FP
METHOD
DATE OF FAMILY SERIAL NAME ADDRESS AGE/ BIRTHDATE TYPE OF CLIENT PREVIOUS METHOD
REGISTRATION NUMBER 3 4 5 6 7
MM/DD/YY 2
1

*TYPE OF CLIENT: CU= current users *PREVIOUS METHOD:

NA= new acceptors CON= condom NFP-BBT= basal body
temperature SDM= standard days method
Other acceptors: INJ= DMPAN or CIC NFP-CM= cervical
mucus method MSTR/VASECTOMY= male ster./vasectomy
*CU-CM= changing method IUD= Intrauterine device (PP-IUD and I-IUD) NFP-STM= Sympothermal
method FSTR/BTL= female ster./bilateral tubal ligation
*CU-CC= changing clinic PILLS= pills NFP-LAM= lactation
amenorrhea method
*CU-RS= restarter IMP= single rod sub-thermal implant
 TARGET CLIENT LIST FOR FAMILY PLANNING
None or NEW ACCEPTORS

FOLLOW-UP VISITS DROP-OUT Remark

(Upper Space: Next Service Date/ Lower Space: Date Accomplished) s or
8 9 Action
Taken
10
1ST 2ND 3RD 4TH 5TH 6TH 7TH 8TH 9TH 10TH 11TH 12TH DATE REASO
N

REASONS:
A= Pregnant G= Menopause M= Underwent Bilateral Salpingo-oophorectomy For
LAM:
B= Desire to become Pregnant H= Lost or Moved out of the Area/Residence N= No FP Commodity A= Mother
has a Menstruation or not ammenorhei
C= medical complications I= Failed to get supply O= Unknown
within 6 months or
 TARGET CLIENT LIST FOR FAMILY PLANNING
D= fear of side Effects J= IUD expelled P= Age Out for BTL B= No longer
practicing fully/ exclusively breastfeeding
E= Change clinic K= Change Method or
F= Husband Disapproves L= Underwent Hysterectomy C= Baby is more than 6
months