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    Pediatric Assessment Form

    Uploaded by

    H Memon

    Copyright:

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

    Pediatric Assessment Form

    Uploaded by

    H Memon
    1 views2 pages

    Copyright

    © © All Rights Reserved

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    PDF, TXT or read online from Scribd

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    Copyright:

    © All Rights Reserved
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    1 views2 pages

    Pediatric Assessment Form

    Uploaded by

    H Memon

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 2

    NUR-FMS

    Clinical Nutrition Clerkship


    Post Graduate Diploma in Clinical Nutrition and Dietetics
    PEDIATRICS NUTRITIONAL ASSESSMENT FORM
    Patient Name: ______________________________________________________ Date: __________________
    Ward/Block: _______________________________________________________ Bed/Room # ____________
    Medical Diagnosis: _________________________________________________________________________

    ANTRHOPOMETRIC MEASUREMENTS

    Age Weight Stature BMI Comments 24 HOUR RECALL


    24 HOUR RECALL
    Bread and Cereals: ___________
    Vegetables: ________________
    Fruits: ____________________
    BMI = Weight (kg) / Stature (cm) / Stature (cm) x 10,000 Meat: _____________________
    Milk Products: ______________
    Head Circumference: ________________________________ Others: ____________________

    Birth Weight: _____________ Weight Gain: _____________

    BIOCHEMICAL TESTS
    GI FUNCTIONS
    Test Result Test Result
    Appetite: __________________
    Nausea: ___________________
    Anorexia: _________________
    Vomiting: _________________
    Constipation: _______________
    Others: ____________________
    Fluid Intake: Oral: _________________ IV: ________________
    Urine Output: ________________________________________

    CLINICAL SIGNS AND SYMPTOMS DIETARY PATTERNS


    Muscle Wasting: □ Wasted Muscle □ Weakness Feeding Practice: ________________
    Gums: □ Swollen □ Fissures Dilution (If bottle fed): ________________
    Nails: □ Pale □ Spoon shaped Formula (If bottle fed): ________________
    Number of feeds per day: ________________
    Tongue: □ Swollen □ Purplish Start of weaning food: ________________
    Hair: □ Dull □ Thin Type of weaning food: ________________
    Skin: □ Dry □ Pale Water Intake: ________________
    Food Allergy (If any): ________________
    Teeth: □ Cavities □ Missing
    Sleep Cycle: ________________
    Eyes: □ Redness □ Dry membrane Physical Activity: ________________
    MEAL TIMINGS HOW OFTEN DOES YOUR CHILD CONSUME
    Breakfast Time THE FOLLOWING IN A WEEK?
    Lunch Time Carbonated Beverages: __________________
    Bakery Products: __________________
    Dinner Time
    Fast Food: __________________
    Canned/Packed Juices: __________________
    MEAL FREQUENTLY SKIPPED Crisps/Snacks: __________________
    Breakfast Candies/Chocolates: __________________
    Lunch Ice-cream: __________________
    Dinner Biscuits/Crackers: __________________

    METABOLIC STATUS
    Low Stress ______________ Moderate Stress ______________ High Stress ______________

    SGA RATING
    Well-nourished: ___________ Malnourished: _______________ Severely Malnourished: ________________

    RECOMMENDATIONS

    Calories Required: _____________________ CHO: ______ Protein: ______ Fats: ______ Fluid: ______

    Mechanism of Diet: ____________________ Type of Diet: ______________________________________

    Supplementation: ______________________ Feeding Route: ____________________________________

    * The patient’s parents have been informed that the clinical information related to their child will be used
    in preparing prevalence report. Name and identity of the patient will be concealed.

    __________________________ _________________________ __________________________


    Parent’s Signature Student’s Signature Doctor’s Signature

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