Bio Data

Name

Guardian Name

Emergency Contact Number

Class

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

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 Rinner 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.56: Girls above 8 years old, ask age of Menarche

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

Question No.58: Any menstrual abnormality

Specify Menstrual Abnormality

Comment/Findings

Psychological

Question No.59: Thought Patterns: How often do you experience negative or intrusive thoughts?

Question No.60: Self-Esteem: How would you rate your overall self-esteem and self-confidence?

Question No.61: Energy Levels: How would you describe your energy levels throughout a typical day?

Question No.62: Coping Strategies: When faced with challenges, what are your typical coping mechanisms?

Question No.63: Sleep Quality: How would you rate the quality of your sleep on average?

Question No.64: Stress Levels: How often have you felt overwhelmed or stressed in the last few weeks?

Question No.65: Mood Assessment: How would you describe your overall mood during the day?

Question No.66: Family Relationships: How would you describe the quality of your relationships with family members?

Question No.67: Problem-Solving Skills: How well do you handle challenges and solve problems?

Question No.68: Sleep Patterns: How many hours of sleep do you typically get on a school night?

Question No.69: Follow-Up Required:

Question No.70: Referred By:

Question: Restless or overactive? (Tell me about his/her focus level. See if the child is shifting by asking a question related to his/her name or which subject he/she likes.)

Question: Excitable, Impulsive? (Ask about aggression level, how often the child engages in fights during class.)

Question: Disturbs other children? (Pin or irritate others, disturbing the whole class.)

Question: Fails to finish things started - short attention span? (Couldn’t complete the task at all.)

Question: Inattentive, easily distracted? (Difficulty following instructions, ask any question and see if the child can follow it.)

Question: Cries often and easily? (How often the child cries during class)

Question: Is your spelling poor? (Ask about 2 spellings like " cook," "him," "her," and see if there are errors.)

Question: When writing down the date, do you often make mistakes? (Ask about the date and see if the child is making a mistake)

Question: Do you find difficulty in telling left from right? (Generally ask about left and right to see the difficulty the child is having)

Question: Do you mix up bus numbers like 35 and 53? (Ask any 2 numbers like 35 and 53 and see if the child is making a mistake or not)

Comment/Findings

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

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

Psychological

Nutritionist