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    NCDC-3 Child Nutritional Status Form Long

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    knock medina
    This document is a child nutritional status and self-help form that collects information about a child's basic details, nutrition, feeding habits, sleeping habits, bathing routine, and toileting for their records at a child development center (CDC). [1] The form requires parents to provide information like the child's name, birthdate, address, contact details, results of height and weight measurements. [2] It also asks questions about the child's eating habits, food allergies, meal and snack times, foods consumed, and whether help is needed for feeding. [3] Further questions cover napping, sleep, bathing frequency, toilet training, and diapering.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd

    NCDC-3 Child Nutritional Status Form Long

    Uploaded by

    knock medina
    203 views4 pages
    This document is a child nutritional status and self-help form that collects information about a child's basic details, nutrition, feeding habits, sleeping habits, bathing routine, and toileting for their records at a child development center (CDC). [1] The form requires parents to provide information like the child's name, birthdate, address, contact details, results of height and weight measurements. [2] It also asks questions about the child's eating habits, food allergies, meal and snack times, foods consumed, and whether help is needed for feeding. [3] Further questions cover napping, sleep, bathing frequency, toilet training, and diapering.

    Original Title

    NCDC-3 CHILD NUTRITIONAL STATUS FORM LONG

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    This document is a child nutritional status and self-help form that collects information about a child's basic details, nutrition, feeding habits, sleeping habits, bathing routine, and toileting for their records at a child development center (CDC). [1] The form requires parents to provide information like the child's name, birthdate, address, contact details, results of height and weight measurements. [2] It also asks questions about the child's eating habits, food allergies, meal and snack times, foods consumed, and whether help is needed for feeding. [3] Further questions cover napping, sleep, bathing frequency, toilet training, and diapering.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    203 views4 pages

    NCDC-3 Child Nutritional Status Form Long

    Uploaded by

    knock medina
    This document is a child nutritional status and self-help form that collects information about a child's basic details, nutrition, feeding habits, sleeping habits, bathing routine, and toileting for their records at a child development center (CDC). [1] The form requires parents to provide information like the child's name, birthdate, address, contact details, results of height and weight measurements. [2] It also asks questions about the child's eating habits, food allergies, meal and snack times, foods consumed, and whether help is needed for feeding. [3] Further questions cover napping, sleep, bathing frequency, toilet training, and diapering.

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    FORM 3

    CHILD NUTRITIONAL STATUS & SELF-HELP FORM

    Instructions to Parents/Guardians: The following information is


    required for your child attending the CDC for record purposes. Please
    complete this form by providing information called for. For some of the
    items, the Municipal/Rural/Barangay Health Unit Officer (M/R/BHUO), or
    Barangay Nutrition Scholars (BNS) is required to provide the
    information. This is to be given to the Child Development Teacher as of
    the child’s portfolio.

    BASIC INFORMATION

    Child’s Name: _______________________________________________________


    Last First Middle

    Birth Date: __________________________ Sex: M F

    Address: ____________________________________________________________

    ___________________________________________________________________

    Parent/Guardian Name(s)______________________ Relationship:


    _____________
    Phone Number(s): Work: ____________________ Home: ____________________
    Mobile Number(s): ________________, _________________, _________________

    NUTRITION INFORMATION:

    Results Date Taken


    Test/Measurement
    1st 2nd 1st 2nd

    Height

    Child Nutritional Status Form Page 1


    Weight

    Nutritional Status

    Name M/R/BHU Phone No.: Signature:


    Officer/BNS:

    Date: ____________________

    FEEDING/EATING:

    1. Does your child have any food allergies we need to be aware of?
    __________
    2. What food do you usually give to your child?
    __________________________
    3. What is your child eating habbit? (i.e. bottles, finger foods, fruits,
    cereal, etc.) _______________________________________________________
    4. Is your child using a bottle? ________ If so, how often will s/he take
    for a day? ________
    5. What time does your child usually have: Breakfast ______ Lunch
    ______ Dinner _______
    6. Is your child used to have a meal time snacks? Yes No

    7. What food is normally eaten by your child?

    Vegetable Rice Pork Cereals Noodles Fruit


    Juice

    Chicken Soup Milk Meat Bread Fish


    Fruits

    8. Does this child need any help in feeding himself/herself? Yes


    No

    NAPPING/SLEEPING:

    Child Nutritional Status Form Page 2


    9. Does your child nap? Yes No

    10. Does your child have a good sleep through the night? Yes
    No

    11. What time does your child get up in the morning? _______________

    12. Does this child have any special nap or bedtime routine? Yes
    No

    BATHING/WASH-UP:
    13. How do you bath/wash-up your child? _____________ How often?
    ________
    14. Do you use baby soap? ____ Any soap? _____ Baby Shampoo?
    _________
    15. Does your child have allergies in soap, shampoo, etc.? Please
    specify; _____
    16. Do you put baby oil after bath/wash-up? ______________ Powder?
    _______

    TOILETING:
    17. Is your child toilet trained? Yes No At what age? ____
    18. Does your child doing any toileting? _______________ How often?
    19. Does your child have a special word for urinating? ___ Bowel
    Movement: ___
    20. Is your child using diaper? ___________ Cloth Disposable
    21. How would you know if your child needs new diaper (S/He brings
    diaper to you, cries, you have to check)?
    ____________________________________
    22. How often do you change his/her diaper/baby clothes?
    __________________

    Child Nutritional Status Form Page 3


    I ATTEST THAT ALL INFORMATION PROVIDED ON THIS FORM IS TRUE
    AND ACCURATE TO THE BEST OF MY KNOWLEDGE AND BELIEF. I
    UNDERSTAND IT IS FOR CONFIDENTIAL USE IN MEETING MY CHILD’S
    HEALTH NEEDS IN NCDC.

    Accomplished by : ______________________________ __________________


    Signature over printed name of parent/guardian
    Date

    Reviewed by: ____________________________


    __________________
    Signature over printed name of CD T
    Date

    Child Nutritional Status Form Page 4

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