Bio Data

Name

Guardian Name

Gender

Class

School

City

Area

Date Of Birth

Age

Emergency Contact Number

GR Number ( only numeric value )

Any Known Medical Condition

Address

Blood Group

Comment/Findings

Vitals/BMI

Height :cm(s)

Question No.2: Weight :kg(s)

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:

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 examinaton

Question No.33:perform a nasal patency test [which involves 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_dose
Rota_2_doses
Measles 2 dose
Never had any vaccination

Comment/Findings

Miscellaneous

Question No.55:Do you have any 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.

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 does you handle challenges and solve problems?

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

Question No.69: followup required?:

Question: Restless or overactive? (tell me about his/her focus level see if the child is shifting by asking him any question related to his/her name, which subject he/she likes)

Question: Excitable, Impulsive? (ask about aggression level, how often child engage in fight during class)

Question:Disturbs other children? (pin or irritate that can disturb the whole class)

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

Question:Inattentive, easily distracted? (difficulty following instructions, generally ask any question and see if the child is able to follow it or not)

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

Question:Is your spelling poor? (ask any 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 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 Protien 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 substances abuse or addiction to

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

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

Question No.70: How many packed items/foods (chips / biscuits sodas) do you consume in average in a day?

Question No.71: How frequently do you consume fast food on dineout on average in a week?

Follow-up Required

Age

Gender

Weight

Height

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

Comment

Dietary Advice Comment

Child Health Checkup Survey

Bio Data

Vitals/BMI

General Apperance

Inspect Hygiene

Head and Neck examination

Eye:

Ears:

Nose

Oral

Throat

Chest

Abdomen

Musculoskeletal

Vaccination:

Miscellaneous

Psychological

Nutritionist