TARGET CLIENT LIST and DISPENSED TO USER RECORD FOR FAMILY PLANNING paulallancenabre02/23/2015

DATE (mm/dd/yyyy)

DATE OF REGISTRATION(mm/dd/yyyy)

NAME(Sur Name, First Name, Middle Initial)

ADDRESS(Purok, Barangay)

AGE

BIRTHDAY(mm/dd/yyyy)

TYPE OF CLIENT PREVIOUS METHOD

FP METHOD SIGNATURE

REMARKS

*Type of Client: CU = Current Users Other Acceptors:NA= New Acceptors *CU-CM = Changing Method

*CU-CC = Changing Clinic* CU- RS= Restarter