1. THESO HELP
AGE COMPOUND
THE HEALTH SUPPORT ORGANIZATION OPP.MINISTRIES’
COMPLEX TEL:+249-728800712;+249-955926092
AVENUE:Wezera
E-MAIL:health@thesoworld.org JUBA-ROSS
URL:www.thesoworld.org
MONTHLY/QUARTERLY REPORT OF HEALTH FACILITY RUN BY THESO
ENDING FIRST WEEK OF NEXT MONTH/QUARTER.
NAME OF FACILITY:…………………………………………………………………………LOCATION:……………………………………
STATE:……………………………………………….. COUNTY:………………………………………...PAYAM:…………………………
REPORT SENT ON :………………………………….MONTH:……………………………………………..YEAR………………………
REPROTING STAFF/PERSON OF HEALTH FACILITY:…………………………………………………...POSITION:…………..
IMPLIMENTING ORGAN OF THE PROJECT:………………………………FROM:…………………………TO:…................
COMPILED BY (THESO staff name,position )……………………………………………………………………………………….
CATCHMENT AREA:……………………………………………………………..POPULATION:………………………………………..
N.B:Refer to ICD-
9 for better
information and
planning
AGE GENDER FREQUENCY OF
VISIT
TOTAL
INDICATOR 1-5yrs 5-14
yrs
15-44
yrs
45&>Yrs M F First Re TOTAL
All age morbid
cases
All morbid cases –
neonates
All mortal cases
All referral cases
Immunization BCG
Immunization-
POLIO
Outbreak mass
immunization
Immunization-
DPT- 1
Immunization-HB
Immunization
DPT-2

2. Immunization-
DPT-3
Immunization-HB
Immunization-
MEASLES
Normal delivery
Abnormal delivery
Still births
Live births
Antenatal IPT 1st
dose
Antenatal 1st
visit
Antenatal IPT 2nd
dose
Antenatal IPT 3rd
dose
Antenatal IPT 4th
dose
C/S delivery
Forceps delivery
Vacuum delivery
Asphyxia
neonatarum
Neonatal jaundice
Post natal visits
Home visits
Family planning
Vitamin A
supplement
Clinical malaria
Confirmed
Malaria
S & C malaria
ARI/Pneumonia
Diarrhea, No DHN
Diarrhea-mod
DHN
Diarrhea-severe
DHN
Severe acute
malnutrition(SAM)
Moderate acute
malnutrition
(MAM)
New PTB smear
Pos cases

3. TB cases under
DOTS
TB cases
default/Failure
TB Transferred
EPTB cases
TB case
Completed DOTS
TB/HIV _Pos
PTC HIV-Pos
PTC HIV-Neg
TB/HIV-Neg
Provision of
PMTCT
PEP for med staff
while at work
HIV-Pos on
ART(new)
HIV-pos on
ART(Previous)
Fever no malaria
STI
Minor surgery
ENT diseases
HPN
DM
Skin diseases
STD
Eye diseases
Onchoscerciasis
Trypanosomiasis
Leshmaniasis
Avitaminosis
Hemorrhagic
fever
Schistomiasis
Enterobious
vermicularis
Tinea species
Omphalitis
Sepsis
Poisoning
Snake
bite,scorpion…

4. This is prepared according to our situation otherwise with time we must use ICD codes adopted by the
MOH of ROSS.
REMARKS &
SIG:……………………………………………………………………………………………………………………………………………………………
…
……………………………………………………………………………………………………………………………………………………...............
....................
FEED BACK &
SIG:……………………………………………………………………………………………………………………………………………………………
.
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