Bio Data

Name

Guardian Name

Emergency Contact Number

Class

Section

School

City

Area

Date Of Birth

Age (Year:Month) {{-- --}}

Gender

GR Number ( only numeric value )

Any Known Medical Condition

Address

Blood Group

Comment/Findings

Vitals/BMI

Height (cm):

Question No.2: Weight (kg):

Question No.3: BMI (Red field means abnomality )

Question No.4: Body Temperature

Question No.5: Blood Pressure (Systolic) (Red field means abnomality )

Question No.6: Blood Pressure (Diastolic) (Red field means abnomality )

Question No.7: Pulse (Red field means abnomality )

Comment/Findings

General Apperance

Question No.8: Normal Posture/Gait

Question No.9: Mental Status

Question No.10: Look For jaundice

Question No.11: Look For anemia

Question No.12: Look For Clubbing

Question No.13: Look for Cyanosis

Question No.14: Skin

Question No.15: Breath

Comment/Findings

Inspect Hygiene

Question No.16: Nails

Question No.17: Uniform or shoes

Question No.18: Lice/nits

Question No.19: Discuss hygiene routines and practices

Comment/Findings

Head and Neck Examination

Question No.20: Hair and Scalp

Question No.21: Any Hair Problem

Question No.22: Scalp

Question No.23: Hair Distribution

Comment/Findings

Eye Examination

Question No.24: Visual acuity using Snellen's chart - Right Eye

Question No.24B: Visual acuity using Snellen's chart - Left Eye

Question No.25: Normal ocular alignment

Question No.26: Normal eye inspection

Question No.27: Normal color vision

Question No.28: Nystagmus

Comment/Findings

Ears:

Question No.29: Normal ears shape and position

Question No.30: Ear examination

Question No.31: Conclusion of hearing test with Rinne and Weber

Comment/Findings

Nose

Question No.32: External nasal examination

Question No.33: Perform a nasal patency test [Gently closing one nostril at a time to assess the patient's ability to breathe through each nostril]

Comment/Findings

Oral

Question No.34: Assess gingiva

Question No.35: Are there dental caries

Comment/Findings

Throat

Question No.36: Examine tonsils

Question No.37: Normal Speech development

Question No.38: Any Neck swelling

Question No.39: Examine lymph node

Comment/Findings

Chest

Question No.40: Any visible chest deformity

Question No.41: Lung Auscultation

Question No.42: Cardiac Auscultation

Comment/Findings

Abdomen

Question No.43: Did you observe any distension, scars, or masses on the child's abdomen?

Question No.44: Any history of abdominal Pain

Comment/Findings

Musculoskeletal

Question No.45: Did you observe any limitations in the child's range of joint motion during your examination?*

Question No.46: Spinal curvature assessment (tick positive finding)

Question No.47: Side-to-side curvature in the spine resembling

Question No.48: Adams forward bend test

Question No.49: Any foot or toe abnormalities

Comment/Findings

Vaccination

Question No.50: Have EPI immunization card?

Question No.50: Mark all the vaccinations that are completed
BCG 1 Dose
OPV 4 Dose
Pentavalent Vaccine (DTP+Hep B+Hib) 3 Doses
Rota 2 Doses
Measles 2 Doses
Never Had Any Vaccination

Comment/Findings

Miscellaneous

Question No.55: Do you have any Allergies

Specify Allergies

Question No.57: Inquire about urinary frequency, urgency, and any pain or discomfort during urination.

Specify Menstrual Abnormality

Comment/Findings

Lead Exposure

Question No. 48: Do you Frequently put things in his/her mouth such as toys, jewelery , or keys?

Question No.49: Does your child eat non-food items(pica)?

Question No. 50: Do you frequently come in contact with an adult whose job involves exposure to lead?

Question No. 51: Do you frequently come in contact with an adult whose hobby involves exposure to lead?

Lead Exposure Result

Comment/Findings

PRE-PRIMARY PSYCHOLOGICAL SCREENER

DEVELOPMENTAL SCREENING

PRIMARY/SECONDARY PSYCHOLOGICAL SCREENER

Age: 6-16 years
Grade: 1-10

Instructions: Ask the child: "In the past few weeks, how often have these things been true for you?"
Ask each question in a child-friendly, age-appropriate way. Mark the response as reported by the child.

You feel sad, unhappy, or like crying.

You are easily distracted or have trouble concentrating.

You feel nervous, worried, or afraid a lot.

You have trouble sleeping or feel tired most of the time.

You feel lonely or like being alone more than usual.

You often argue or talk back when told to do something.

You take things that do not belong to you or refuse to share.

You fight with other children or get angry quickly.

You don’t enjoy things you used to enjoy.

You are clingy or need to be with adults all the time.

You have trouble sitting still or feel “on the go” a lot.

You don’t listen to rules or directions.

Internalizing Result

Internalizing Total Score:

Externalizing Result

Externalizing Total Score:

Attention Result

Attention Total Score:

Psychological Assessment Comments:

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Nutritionist

Question No.60: How would you describe your lifestyle?

Question No.61: BMI

Question No.62: MUAC

Question No.63: Daily Protein Requirement )

Question No.64: Daily Energy
Requirement

Question No.65: How many glasses of water/liquids do you consume in a day?

{{--

Question No.66: Does the child have any history of substance abuse or addiction?

--}}

Question No.66: Does the child have any history of substances abuse or addiction to

Question No.67: Does the child suffer from any food intolerances or allergies?

Question No.69: How many meals (breakfast, lunch, dinner) do you consume in a day?

Question No.70: How many packed items (chips, biscuits, sodas) do you consume daily?

Question No.71: How frequently do you consume fast food (dine-out) in a week?

Follow-up Required

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Age (Year:Month) {{-- --}}

Gender

Weight

Height

{{-- ---------------------- For Wasting criteria -------------------------- --}} {{-- -------------------------------- STUNTING CRITERIA ------------------------------------ --}}

Nutrition Comment

Dietary Advice Comment

Doctor Comment

Child Health Checkup Survey

Bio Data

Vitals/BMI

General Apperance

Inspect Hygiene

Head and Neck Examination

Eye Examination

Ears:

Nose

Oral

Throat

Chest

Abdomen

Musculoskeletal

Vaccination

Miscellaneous

Lead Exposure

PRE-PRIMARY PSYCHOLOGICAL SCREENER

DEVELOPMENTAL SCREENING

SOCIAL EMOTIONAL BEHAVIORAL SCREENING

AUTISM SPECTRUM DISORDER SCREENING

PRIMARY/SECONDARY PSYCHOLOGICAL SCREENER

Nutritionist