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Nutrition Card

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Ibrahim Abdela
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165 views4 pages

Nutrition Card

Uploaded by

Ibrahim Abdela
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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Federal Ministry of Health

NutritionCard Page 1
MothersName------------------------------- Dateof Birth (DOB)……./……. /………IndividualID
Name of the child ----------------------------- Date of Birth (DOB)…….../……. /……… Individual ID Sex

EarlyInitiationofBreastfeedingwithinonehourofdeliveryYESNoDateofcomplementaryfeedingstarted(DD/ MM/YY
Year(EFY)
PSNPBeneficiary(Yes/No)
GrowthMonitoringandPromotion(Undertwo-yearchildonly)
Age (Month) 1 2 3 4 5 6 7 8 9 10 11 12
DD
Date of visit MM
YYYY
Weight(kg)
WFA Classification*
TimeandAgeappropriatecounselingservice(Y/N)
EBF(Y/N)
Dietary diversity (Yes/No)
Complementar
y feeding

Food frequency (Yes/No)

Food consistency (Yes/No)


Age (Month) 13 14 15 16 17 18 19 20 21 22 23 24
DD
Date of visit MM
YYYY
Weight(kg)
WFAClassification(*)
TimeandAgeappropriatenutritioncounselingservice(Y/N)

Dietary diversity (Yes/No)


Complementar

Food frequency (Yes/No)


y feeding

Food consistency (Yes/No)

VitaminAandDewormingsupplementationforchildren
YearEFY(YY)
Dose per year 1st 2nd 1st 2nd 1st 2nd 1st 2nd 1st 2nd 1st 2nd
Visitdate(DD/MM)
Vit. A
Age in Month
Visitdate(DD/MM)
Deworming
Age in Month
MaternalCounseling onFamily planning
Counseledon FP(Y/N)
UsingModernFP(Writecode)
Write code for
Write:CodeforGMPClassificationbasedonweight FPFeC=FemalecondomOC=
N: for Normal OralcontraceptiveEc=Emerge
MU:forModerateUnderweightS ncyContraceptiveInj=Injectab
U: Severely underweight le
Imp=ImplanonJad=J
adielOth=Other
Federal Ministry of Health

Nutritional Screening Page 2


Age(inmonth) <1 1 2 3 4 5 6 7 8 9 10 11
DD
Visitdate MM
YY
0-6-month(Visiblewasting)Y/N
MUAC in cm (6-59 Months)
Bilateral Pitting Edema (Yes/No)
Classification(N,MAM,SAM)
Referredto(OTP,SC,TSFPandPSNP)
Nutritional counselling provided (Y/N)
Age(inmonth) 12 13 14 15 16 17 18 19 20 21 22 23
DD
Visitdate MM
YY
MUAC in cm (6-59 Months)
Bilateral Pitting Edema (Yes/No)
Classification(N,MAM,SAM)
Nutritional Counselling(Y/N)
Referredto(OTP,SC,TSFPandPSNP)
Age(inmonth) 24 25 26 27 28 29 30 31 32 33 34 35
DD
Visitdate MM
YY
MUAC in cm (6-59 Months)
Bilateral Pitting Edema (Yes/No)
Classification(N,MAM,SAM)
Nutritional Counselling (Y/N)
Referredto(OTP,SC,TSFPandPSNP)
Age(inmonth) 36 37 38 39 40 41 42 43 44 45 46 47
DD
Visitdate MM
YY
MUAC in cm (6-59 Months)
Bilateral Pitting Edema (Yes/No)
Classification(N,MAM,SAM)
Nutritional Counselling (Y/N)
Referredto(OTP,SC,TSFPandPSNP)
Age(inmonth) 48 49 50 51 52 53 54 55 56 57 58 59
DD
Visitdate MM
YY
MUAC in cm (6-59 Months)
Bilateral Pitting Edema (Yes/No)
Classification(N,MAM,SAM)
Nutritional Counselling
Referredto(OTP,SC,TSFPandPSNP)
Writecodeforscreeningclassification WritecodeforReferral
OTP=Referred to Outpatient program
N= Normal, SC=ReferredtoStabilizationcenter(HealthcenterorHospital)
MAM=ModerateAcutemalnutrition TSFP =Referred to Target Supplementary Feeding program
SAM =Severe Acute Malnutrition PSNP= Referred to Productive Safety net Program
Federal Ministry of Health

OTPAdmissionanddischarge Page 3
Individual ID
Year
Admission: TargetWeight(Kg)
OTPDischarge
OTPadmissionDate(DD/ 1. New
Date(DD/
MM/YYYY) 2. Return after defaulter
MM/YYYY)
3. Readmission

Age (in Month) Sent by WDA From EOS/CHD/HEP lf-referral Others/

Se
Admissionanthropometry
WFH Edema (0,
Weight(Kg) Height(cm) MUAC (cm)
(%) +,++,++)
History and physical Examination
Tempera-
RespirationRate(#min) <30 30-40 40 - 49 50+ Febrile Norm Vomiting(Y/N)
ture(0C)
al

Blood in the stool(Y/N) Breastfeeding(Y/N) Cough(Y/N) Diarrhea(Y/N)

OTPfollowUP
Week Adm. 2 3 4 5 6 7 8 9 10 11 12
Date
Anthropometry
Weight(Kg)
WeightChange(+,0,-)
MUAC (cm)
Edema (0, +, ++, +++)
General DangerSigns
Seizures(#days)
Lethargic(#days)
Vomitingeverything(Y/N)
Unable to feed(Y/N)
History
Diarrhea (# days)
Blood in Stool(Y/N)
Vomiting(#days)
Fever (# days)
Cough (# days)
Physical Examination
AppetiteTest(Pass/failed)
Temperature(oc)
Respiratory Rate (# /Min)
Dermatosis(0,+,++,+++)
Action Needed(Y/N)
Routine Medication
Amoxicillin
Measles
Folic acid
VitaminA
Deworming
RUTF(#sachets)
Outcome*
***A=absentDF=defaulter(Patientthatisabsentfortwo21daysinout-
patientconfirmedbyahomevisit.)T=transfertoTFUX=diedC=dischargedcuredRT=refusedtransferHV=homevisitNR=Non-
responder(didnotfulfilldischargecriteriaafter8WKstreatment)U=Unknown(Patientthatisabsentfor21days in out-patient but his outcome (actual defaulting or
death) is not confirmed/ verified by a home visit)
Actiontaken

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