Chart Cerebral Palsy PDF

Chart Gizi Pasien Anak dengan
Cerebral Palsy
GMFCS (gross motor function classification
system)
With level 5 additionally divided into those
requiring a feeding tube (TF) and those not (NT).
1.
2.
3.
4.
Walks without limitations

Walks with limitations
Walks using a hand-held mobility device
Self-mobility with limitations, may use
powered mobility
5. Transported in a manual wheelchair
2 to 20 years: Boys
Cerebral palsy
GMFCS I
Weightforage percentiles
NAME _____________________________
RECORD # ____________
Mother's Stature:___________ Father's Stature:___________
Date
Age
Stature
Weight
230 105
BMI
220 100
95
210
200
95
90
90
Notes:
190
85
180
80
170
75
75
160
Low weight (see text)
70
150
50
120
W
E
65
I
G
60
H
T
55
110
50
100
45
140
130
25
10
5
90
35
W
E
I
G
H
T
80
80
70
70
30
60
60
50
50
40
40
30
30
20
20
25
20
10
5
kg
35
30
25
15
40
20
10
lbs
10
lbs
AGE (YEARS)
2
10
11
12
13
14
15
16
17
18
19
15
10
5
kg
20
SOURCE: Life Expectancy Project (2011)

Based on data from the California Department of Developmental Services and California Bureau of Vital Statistics
http://www.LifeExpectancy.org/Articles/NewGrowthCharts.shtml
2 to 20 years: Boys
Cerebral palsy
GMFCS I
Statureforage percentiles
NAME _____________________________
RECORD # ____________

200
78
Date
Stature
BMI
Age
Weight
195
76
190
74
185
72
180
70
Notes:
175
68
170
66
165
64
160
62
155
60
150
58
145
56
140
54
135
52
130
50
125
48
120
46
115
44
110
42
105
40
100
38
95
S
36
90
T
34
A 85
78
76
95
74
90
72
75
70
68
50
66
25
64
200
195
190
185
S
180 T
175 A
T
170
U
165 R
160 E
62
155
10
60
150
58
145
56
140
54
52
50
48
46
44
42
40
38
36
34
32
32
135
130
125
120
115
110
105
100
95
90
85
80
75
30
30
75
70
28
28
70
65
26
26
65
60
24
24
60
22
in
55
cm
R
E
55
cm
AGE (YEARS)
22
in
2
10
11
12
13
14
15

Based on data from the California Department of Developmental Services
16
17
18
19
20
80
2 to 20 years: Boys
Cerebral palsy
GMFCS I
BMIforage percentiles
NAME _____________________________
RECORD # ____________
36
Date
Age
Stature
Weight
36
BMI
BMI*
35
35
34
34
95
33
33
Notes:
32
32
31
31
*To Calculate BMI: Weight (kg) Stature (cm) Stature (cm) 10,000
30
or Weight (lb) Stature (in) Stature (in) 703
90
30
29
BMI
29
28
28
27
27
75
26
26
25
25
24
24
23
23
50
22
22
21
21
20
20
25
19
19
18
18
10
17
17
5
16
16
15
15
14
14
13
13
12
12
kg/m2
kg/m2
AGE (YEARS)
2
10
11
12
13
14
15

16
17
18
19
20
2 to 20 years: Boys
Cerebral palsy
GMFCS II
NAME _____________________________
RECORD # ____________
Date
Age
Stature
Weight
230 105
BMI
220 100
210
200
95
Notes:
190
95
90
85
180
90
80
170
75
160
70
75
150
120
W
E
65
I
G
60
H
T
55
110
50
100
45
140
130
50
25
10
35
W
E
I
G
H
T
90
80
80
70
30
60
60
50
50
40
40
30
30
20
20
25
25
20
10
5
kg
35
70
30
15
40
20
10
lbs
10
lbs
AGE (YEARS)
2
10
11
12
13
14
15
16
17
18
19
15
10
5
kg
20

2 to 20 years: Boys
Cerebral palsy
GMFCS II
NAME _____________________________
RECORD # ____________

200
78
Date
Stature
BMI
Age
Weight
195
76
190
74
185
72
180
70
Notes:
175
68
170
66
165
64
160
62
155
60
150
58
145
56
140
54
135
52
130
50
125
48
120
46
115
44
110
42
105
40
100
38
95
S
36
90
T
34
A 85
78
76
74
95
72
90
70
68
75
66
50
64
200
195
190
185
S
180 T
175 A
T
170
U
165 R
160 E
62
25
155
60
150
10
58
145
56
140
54
52
50
48
46
44
42
40
38
36
34
32
32
135
130
125
120
115
110
105
100
95
90
85
80
75
30
30
75
70
28
28
70
65
26
26
65
60
24
24
60
22
in
55
cm
R
E
55
cm
AGE (YEARS)
22
in
2
10
11
12
13
14
15

16
17
18
19
20
80
2 to 20 years: Boys
Cerebral palsy
GMFCS II
NAME _____________________________
RECORD # ____________
36
Date
Age
Stature
Weight
36
BMI
BMI*
35
35
34
34
33
33
Notes:
32
32
95
31
31
30
30
29
BMI
29
90
28
28
27
27
26
26
25
25
75
24
24
23
23
22
22
50
21
21
20
20
19
19
25
18
18
17
17
10
16
16
5
15
15
14
14
13
13
12
12
kg/m2
kg/m2
AGE (YEARS)
2
10
11
12
13
14
15

16
17
18
19
20
2 to 20 years: Boys
Cerebral palsy
GMFCS III
NAME _____________________________
RECORD # ____________
Date
Age
Stature
Weight
230 105
BMI
220 100
210
200
95
90
Notes:
190
85
180
80
95
170
75
160
90
70
150
120
W
E
65
I
G
60
H
T
55
110
50
100
45
140
75
130
50
25
35
W
E
I
G
H
T
90
80
80
10
70
30
60
60
50
50
40
40
30
30
20
20
25
25
20
10
5
kg
35
70
30
15
40
20
10
lbs
10
lbs
AGE (YEARS)
2
10
11
12
13
14
15
16
17
18
19
15
10
5
kg
20

2 to 20 years: Boys
Cerebral palsy
GMFCS III
NAME _____________________________
RECORD # ____________

200
78
Date
Stature
BMI
Age
Weight
195
76
190
74
185
72
180
70
Notes:
175
68
170
66
165
64
160
62
155
60
150
58
145
56
140
54
135
52
130
50
125
48
120
46
115
44
110
42
105
40
100
38
95
S
36
90
T
34
A 85
78
76
74
72
95
70
90
68
66
75
64
200
195
190
185
S
180 T
175 A
T
170
U
165 R
160 E
50
62
155
60
150
25
58
145
56
140
10
54
52
50
48
46
44
42
40
38
36
34
32
32
135
130
125
120
115
110
105
100
95
90
85
80
75
30
30
75
70
28
28
70
65
26
26
65
60
24
24
60
22
in
55
cm
R
E
55
cm
AGE (YEARS)
22
in
2
10
11
12
13
14
15

16
17
18
19
20
80
2 to 20 years: Boys
Cerebral palsy
GMFCS III
NAME _____________________________
RECORD # ____________
36
Date
Age
Stature
Weight
36
BMI
BMI*
35
35
34
34
33
33
Notes:
32
32
31
31
95
30
30
29
BMI
29
28
28
90
27
27
26
26
25
25
24
24
75
23
23
22
22
21
21
50
20
20
19
19
18
18
25
17
17
16
16
10
15
15
5
14
14
13
13
12
12
kg/m2
kg/m2
AGE (YEARS)
2
10
11
12
13
14
15

16
17
18
19
20
2 to 20 years: Boys
Cerebral palsy
GMFCS IV
NAME _____________________________
RECORD # ____________
Date
Age
Stature
Weight
230 105
BMI
220 100
210
200
95
90
Notes:
190
85
180
80
170
75
95
160
70
150
120
W
E
65
I
G
60
H
T
55
110
50
100
45
90
140
130
75
50
90
35
W
E
I
G
H
T
80
80
25
70
30
10
60
60
25
25
50
50
40
40
30
30
20
20
20
10
5
kg
35
70
30
15
40
20
10
lbs
10
lbs
AGE (YEARS)
2
10
11
12
13
14
15
16
17
18
19
15
10
5
kg
20

2 to 20 years: Boys
Cerebral palsy
GMFCS IV
NAME _____________________________
RECORD # ____________

200
78
Date
Stature
BMI
Age
Weight
195
76
190
74
185
72
180
70
Notes:
175
68
170
66
165
64
160
62
155
60
150
58
145
56
140
54
135
52
130
50
125
48
120
46
115
44
110
42
105
40
100
38
95
S
36
90
T
34
A 85
78
76
74
72
95
70
90
68
66
75
64
200
195
190
185
S
180 T
175 A
T
170
U
165 R
160 E
62
155
50
60
150
58
145
25
56
140
54
52
10
50
5
48
46
44
42
40
38
36
34
32
32
135
130
125
120
115
110
105
100
95
90
85
80
75
30
30
75
70
28
28
70
65
26
26
65
60
24
24
60
22
in
55
cm
R
E
55
cm
AGE (YEARS)
22
in
2
10
11
12
13
14
15

16
17
18
19
20
80
2 to 20 years: Boys
Cerebral palsy
GMFCS IV
NAME _____________________________
RECORD # ____________
36
Date
Age
Stature
Weight
36
BMI
BMI*
35
35
34
34
33
33
Notes:
32
32
31
31
95
30
30
29
BMI
29
28
28
90
27
27
26
26
25
25
24
24
23
23
75
22
22
21
21
20
20
19
19
50
18
18
17
17
25
16
16
15
15
14
10
14
13
13
12
12
kg/m2
kg/m2
AGE (YEARS)
2
10
11
12
13
14
15

16
17
18
19
20
2 to 20 years: Boys
Cerebral palsy
GMFCS V, feeds orally
NAME _____________________________
RECORD # ____________
Date
Age
Stature
Weight
230 105
BMI
220 100
210
200
95
90
Notes:
190
85
180
80
170
75
160
70
150
120
W
E
65
I
G
60
H
T
55
110
50
100
45
140
130
95
90
75
90
35
W
E
I
G
H
T
80
80
50
70
30
25
60
60
25
25
10
50
5
kg
50
20
10
35
70
30
15
40
20
40
40
30
30
20
20
10
lbs
10
lbs
AGE (YEARS)
2
10
11
12
13
14
15
16
17
18
19
15
10
5
kg
20

2 to 20 years: Boys
Cerebral palsy
NAME _____________________________
RECORD # ____________

200
78
Date
Stature
BMI
Age
Weight
195
76
190
74
185
72
180
70
Notes:
175
68
170
66
165
64
160
62
155
60
150
58
145
56
140
54
135
52
130
50
125
48
120
46
115
44
110
42
105
40
100
38
95
S
36
90
T
34
A 85
78
76
74
72
70
95
68
90
66
64
200
195
190
185
S
180 T
175 A
T
170
U
165 R
160 E
62
75
155
60
150
58
50
145
56
140
54
25
52
50
10
48
46
44
42
40
38
36
34
32
32
135
130
125
120
115
110
105
100
95
90
85
80
75
30
30
75
70
28
28
70
65
26
26
65
60
24
24
60
22
in
55
cm
R
E
55
cm
AGE (YEARS)
22
in
2
10
11
12
13
14
15

16
17
18
19
20
80
2 to 20 years: Boys
Cerebral palsy
NAME _____________________________
RECORD # ____________
36
Date
Age
Stature
Weight
36
BMI
BMI*
35
35
34
34
33
33
Notes:
32
32
31
31
30
30
29
BMI
29
28
28
27
27
26
26
95
25
25
24
24
23
23
90
22
22
21
21
20
20
75
19
19
18
18
17
17
50
16
16
15
15
25
14
14
13
10
13
12
12
kg/m2
kg/m2
AGE (YEARS)
2
10
11
12
13
14
15

16
17
18
19
20
2 to 20 years: Boys
Cerebral palsy
GMFCS V, tube fed
NAME _____________________________
RECORD # ____________
Date
Age
Stature
Weight
230 105
BMI
220 100
210
200
95
90
Notes:
190
85
180
80
170
75
160
70
150
120
W
E
65
I
G
60
H
T
55
110
50
100
45
140
130
95
90
75
90
35
W
E
I
G
H
T
50
80
80
70
30
60
60
10
25
25
50
50
20
10
5
kg
35
70
25
30
15
40
20
40
40
30
30
20
20
10
lbs
10
lbs
AGE (YEARS)
2
10
11
12
13
14
15
16
17
18
19
15
10
5
kg
20

2 to 20 years: Boys
Cerebral palsy
GMFCS V, tube fed
NAME _____________________________
RECORD # ____________

200
78
Date
Stature
BMI
Age
Weight
195
76
190
74
185
72
180
70
Notes:
175
68
170
66
165
64
160
62
155
60
150
58
145
56
140
54
135
52
130
50
125
48
120
46
115
44
110
42
105
40
100
38
95
S
36
90
T
34
A 85
78
76
74
72
70
68
95
66
90
64
200
195
190
185
S
180 T
175 A
T
170
U
165 R
160 E
62
75
155
60
150
58
50
145
56
140
54
25
52
50
10
48
5
46
44
42
40
38
36
34
32
32
135
130
125
120
115
110
105
100
95
90
85
80
75
30
30
75
70
28
28
70
65
26
26
65
60
24
24
60
22
in
55
cm
R
E
55
cm
AGE (YEARS)
22
in
2
10
11
12
13
14
15

16
17
18
19
20
80
2 to 20 years: Boys
Cerebral palsy
GMFCS V, tube fed
NAME _____________________________
RECORD # ____________
36
Date
Age
Stature
Weight
36
BMI
BMI*
35
35
34
34
33
33
Notes:
32
32
31
31
30
30
29
BMI
29
28
28
27
27
26
26
95
25
25
24
24
90
23
23
22
22
21
21
75
20
20
19
19
18
18
50
17
17
16
16
25
15
15
14
14
10
13
13
5
12
12
kg/m2
kg/m2
AGE (YEARS)
2
10
11
12
13
14
15

16
17
18
19
20
2 to 20 years: Girls
Cerebral palsy
GMFCS I
NAME _____________________________
RECORD # ____________
Date
Age
Stature
Weight
230 105
BMI
220 100
210
200
Notes:
95
90
95
190
85
180
80
90
170
75
160
70
150
75
120
W
E
65
I
G
60
H
T
55
110
50
100
45
140
130
50
25
10
90
5
35
W
E
I
G
H
T
80
80
70
70
30
60
60
50
50
40
40
30
30
20
20
25
20
10
5
kg
35
30
25
15
40
20
10
lbs
10
lbs
AGE (YEARS)
2
10
11
12
13
14
15
16
17
18
19
15
10
5
kg
20

Cerebral palsy
GMFCS I
NAME _____________________________
RECORD # ____________

200
78
Date
Stature
BMI
Age
Weight
195
76
190
74
185
72
180
70
Notes:
175
68
170
66
165
64
160
62
155
60
150
58
145
56
140
54
135
52
130
50
125
48
120
46
115
44
110
42
105
40
100
38
95
S
36
90
T
34
A 85
78
76
74
72
70
68
95
90
66
75
64
50
62
25
60
200
195
190
185
S
180 T
175 A
T
170
U
165 R
160 E
155
150
58
145
10
56
140
54
52
50
48
46
44
42
40
38
36
34
32
32
135
130
125
120
115
110
105
100
95
90
85
80
75
30
30
75
70
28
28
70
65
26
26
65
60
24
24
60
22
in
55
cm
R
E
55
cm
AGE (YEARS)
22
in
2
10
11
12
13
14
15

16
17
18
19
20
80
Cerebral palsy
GMFCS I
NAME _____________________________
RECORD # ____________
36
Date
Age
Stature
Weight
36
BMI
BMI*
95
35
35
34
34
33
33
Notes:
32
32
90
31
31
30
30
29
BMI
29
28
28
75
27
27
26
26
25
25
24
24
50
23
23
22
22
21
21
25
20
20
19
19
18
10
18
17
17
16
16
15
15
14
14
13
13
12
12
kg/m2
kg/m2
AGE (YEARS)
2
10
11
12
13
14
15

16
17
18
19
20
Cerebral palsy
GMFCS II
NAME _____________________________
RECORD # ____________
Date
Age
Stature
Weight
230 105
BMI
220 100
210
200
95
90
Notes:
190
95
85
180
80
170
75
90
160
70
150
120
W
E
65
I
G
60
H
T
55
110
50
100
45
140
75
130
50
25
90
40
10
35
W
E
I
G
H
T
80
80
5
70
70
30
30
60
60
50
50
40
40
30
30
20
20
25
25
20
15
10
5
kg
35
20
10
lbs
10
lbs
AGE (YEARS)
2
10
11
12
13
14
15
16
17
18
19
15
10
5
kg
20

Cerebral palsy
GMFCS II
NAME _____________________________
RECORD # ____________

200
78
Date
Stature
BMI
Age
Weight
195
76
190
74
185
72
180
70
Notes:
175
68
170
66
165
64
160
62
155
60
150
58
145
56
140
54
135
52
130
50
125
48
120
46
115
44
110
42
105
40
100
38
95
S
36
90
T
34
A 85
78
76
74
72
70
68
95
66
90
64
75
200
195
190
185
S
180 T
175 A
T
170
U
165 R
160 E
62
155
50
60
150
25
58
145
56
10
140
54
52
50
48
46
44
42
40
38
36
34
32
32
135
130
125
120
115
110
105
100
95
90
85
80
75
30
30
75
70
28
28
70
65
26
26
65
60
24
24
60
22
in
55
cm
R
E
55
cm
AGE (YEARS)
22
in
2
10
11
12
13
14
15

16
17
18
19
20
80
Cerebral palsy
GMFCS II
NAME _____________________________
RECORD # ____________
36
Date
Age
Stature
Weight
36
BMI
BMI*
35
35
34
34
95
33
33
Notes:
32
32
31
31
90
30
30
29
BMI
29
28
28
27
27
75
26
26
25
25
24
24
23
23
50
22
22
21
21
20
20
25
19
19
18
18
17
10
17
16
16
15
15
14
14
13
13
12
12
kg/m2
kg/m2
AGE (YEARS)
2
10
11
12
13
14
15

16
17
18
19
20
Cerebral palsy
GMFCS III
NAME _____________________________
RECORD # ____________
Date
Age
Stature
Weight
230 105
BMI
220 100
210
200
95
90
Notes:
190
85
180
80
170
75
95
160
70
150
120
W
E
65
I
G
60
H
T
55
110
50
100
45
90
140
130
75
50
90
25
35
W
E
I
G
H
T
80
80
10
70
30
60
60
50
50
40
40
30
30
20
20
25
25
20
15
10
5
kg
35
70
30
40
20
10
lbs
10
lbs
AGE (YEARS)
2
10
11
12
13
14
15
16
17
18
19
15
10
5
kg
20

Cerebral palsy
GMFCS III
NAME _____________________________
RECORD # ____________

200
78
Date
Stature
BMI
Age
Weight
195
76
190
74
185
72
180
70
Notes:
175
68
170
66
165
64
160
62
155
60
150
58
145
56
140
54
135
52
130
50
125
48
120
46
115
44
110
42
105
40
100
38
95
S
36
90
T
34
A 85
78
76
74
72
70
68
95
66
90
64
200
195
190
185
S
180 T
175 A
T
170
U
165 R
160 E
75
62
50
60
155
150
58
145
25
56
140
54
10
52
5
50
48
46
44
42
40
38
36
34
32
32
135
130
125
120
115
110
105
100
95
90
85
80
75
30
30
75
70
28
28
70
65
26
26
65
60
24
24
60
22
in
55
cm
R
E
55
cm
AGE (YEARS)
22
in
2
10
11
12
13
14
15

16
17
18
19
20
80
Cerebral palsy
GMFCS III
NAME _____________________________
RECORD # ____________
36
Date
Age
Stature
Weight
36
BMI
BMI*
35
35
34
34
33
33
Notes:
32
95
32
31
31
30
30
29
BMI
90
29
28
28
27
27
26
26
25
25
75
24
24
23
23
22
22
21
21
50
20
20
19
19
18
18
25
17
17
16
16
10
15
15
14
14
13
13
12
12
kg/m2
kg/m2
AGE (YEARS)
2
10
11
12
13
14
15

16
17
18
19
20
Cerebral palsy
GMFCS IV
NAME _____________________________
RECORD # ____________
Date
Age
Stature
Weight
230 105
BMI
220 100
210
200
95
90
Notes:
190
85
180
80
170
75
160
70
150
120
W
E
65
I
G
60
H
T
55
110
50
100
45
95
140
90
130
75
50
35
W
E
I
G
H
T
90
80
80
25
70
30
10
60
25
60
25
50
50
40
40
30
30
20
20
20
10
5
kg
35
70
30
15
40
20
10
lbs
10
lbs
AGE (YEARS)
2
10
11
12
13
14
15
16
17
18
19
15
10
5
kg
20

Cerebral palsy
GMFCS IV
NAME _____________________________
RECORD # ____________

200
78
Date
Stature
BMI
Age
Weight
195
76
190
74
185
72
180
70
Notes:
175
68
170
66
165
64
160
62
155
60
150
58
145
56
140
54
135
52
130
50
125
48
120
46
115
44
110
42
105
40
100
38
95
S
36
90
T
34
A 85
78
76
74
72
70
68
95
66
90
64
200
195
190
185
S
180 T
175 A
T
170
U
165 R
160 E
62
75
155
60
150
50
58
145
56
140
25
54
52
10
50
48
46
44
42
40
38
36
34
32
32
135
130
125
120
115
110
105
100
95
90
85
80
75
30
30
75
70
28
28
70
65
26
26
65
60
24
24
60
22
in
55
cm
R
E
55
cm
AGE (YEARS)
22
in
2
10
11
12
13
14
15

16
17
18
19
20
80
Cerebral palsy
GMFCS IV
NAME _____________________________
RECORD # ____________
36
Date
Age
Stature
Weight
36
BMI
BMI*
35
35
34
34
33
33
Notes:
32
32
31
31
95
30
30
29
BMI
29
28
28
90
27
27
26
26
25
25
24
24
75
23
23
22
22
21
21
20
20
50
19
19
18
18
17
17
25
16
16
15
15
10
14
14
13
13
12
12
kg/m2
kg/m2
AGE (YEARS)
2
10
11
12
13
14
15

16
17
18
19
20
Cerebral palsy
NAME _____________________________
RECORD # ____________
Date
Age
Stature
Weight
230 105
BMI
220 100
210
200
95
90
Notes:
190
85
180
80
170
75
160
70
150
95
120
W
E
65
I
G
60
H
T
55
90
110
50
100
45
140
130
75
35
W
E
I
G
H
T
90
80
80
50
70
30
60
25
60
50
10
50
25
25
5
20
10
5
kg
35
70
30
15
40
20
40
40
30
30
20
20
10
lbs
10
lbs
AGE (YEARS)
2
10
11
12
13
14
15
16
17
18
19
15
10
5
kg
20

Cerebral palsy
NAME _____________________________
RECORD # ____________

200
78
Date
Stature
BMI
Age
Weight
195
76
190
74
185
72
180
70
Notes:
175
68
170
66
165
64
160
62
155
60
150
58
145
56
140
54
135
52
130
50
125
48
120
46
115
44
110
42
105
40
100
38
95
S
36
90
T
34
A 85
78
76
74
72
70
68
66
95
64
90
62
200
195
190
185
S
180 T
175 A
T
170
U
165 R
160 E
155
60
75
150
58
145
56
50
140
54
52
25
50
48
10
46
5
44
42
40
38
36
34
32
32
135
130
125
120
115
110
105
100
95
90
85
80
75
30
30
75
70
28
28
70
65
26
26
65
60
24
24
60
22
in
55
cm
R
E
55
cm
AGE (YEARS)
22
in
2
10
11
12
13
14
15

16
17
18
19
20
80
Cerebral palsy
NAME _____________________________
RECORD # ____________
36
Date
Age
Stature
Weight
36
BMI
BMI*
35
35
34
34
33
33
Notes:
32
32
31
31
30
30
29
BMI
29
28
28
95
27
27
26
26
25
25
90
24
24
23
23
22
22
21
21
75
20
20
19
19
18
18
50
17
17
16
16
15
15
25
14
14
13
10
13
12
12
kg/m2
kg/m2
AGE (YEARS)
2
10
11
12
13
14
15

16
17
18
19
20
Cerebral palsy
GMFCS V, tube fed
NAME _____________________________
RECORD # ____________
Date
Age
Stature
Weight
230 105
BMI
220 100
210
200
95
90
Notes:
190
85
180
80
170
75
160
70
150
120
W
E
65
I
G
60
H
T
55
110
50
100
45
140
130
95
90
75
35
W
E
I
G
H
T
80
90
80
50
70
30
25
60
60
25
25
10
50
50
20
10
5
kg
35
70
30
15
40
20
40
40
30
30
20
20
10
lbs
10
lbs
AGE (YEARS)
2
10
11
12
13
14
15
16
17
18
19
15
10
5
kg
20

Cerebral palsy
GMFCS V, tube fed
NAME _____________________________
RECORD # ____________

200
78
Date
Stature
BMI
Age
Weight
195
76
190
74
185
72
180
70
Notes:
175
68
170
66
165
64
160
62
155
60
150
58
145
56
140
54
135
52
130
50
125
48
120
46
115
44
110
42
105
40
100
38
95
S
36
90
T
34
A 85
78
76
74
72
70
68
66
64
95
200
195
190
185
S
180 T
175 A
T
170
U
165 R
160 E
90
62
75
60
155
150
58
145
50
56
140
54
52
25
50
48
10
46
44
42
40
38
36
34
32
32
135
130
125
120
115
110
105
100
95
90
85
80
75
30
30
75
70
28
28
70
65
26
26
65
60
24
24
60
22
in
55
cm
R
E
55
cm
AGE (YEARS)
22
in
2
10
11
12
13
14
15

16
17
18
19
20
80
Cerebral palsy
GMFCS V, tube fed
NAME _____________________________
RECORD # ____________
36
Date
Age
Stature
Weight
36
BMI
BMI*
35
35
34
34
33
33
Notes:
32
32
31
31
30
30
29
BMI
29
28
28
27
27
95
26
26
25
25
24
24
90
23
23
22
22
21
21
75
20
20
19
19
18
18
50
17
17
16
16
25
15
15
14
14
10
13
13
5
12
12
kg/m2
kg/m2
AGE (YEARS)
2
10
11
12
13
14
15

16
17
18
19
20

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Mother's Stature:___________ Father's Stature:___________

Low weight (see text)

SOURCE: Life Expectancy Project (2011)

Mother's Stature:___________ Father's Stature:___________

SOURCE: Life Expectancy Project (2011)

Mother's Stature:___________ Father's Stature:___________

SOURCE: Life Expectancy Project (2011)

Mother's Stature:___________ Father's Stature:___________

Low weight (see text)

SOURCE: Life Expectancy Project (2011)

Mother's Stature:___________ Father's Stature:___________

SOURCE: Life Expectancy Project (2011)

Mother's Stature:___________ Father's Stature:___________

SOURCE: Life Expectancy Project (2011)

Mother's Stature:___________ Father's Stature:___________

Low weight (see text)

SOURCE: Life Expectancy Project (2011)

Mother's Stature:___________ Father's Stature:___________

SOURCE: Life Expectancy Project (2011)

Mother's Stature:___________ Father's Stature:___________

SOURCE: Life Expectancy Project (2011)

Mother's Stature:___________ Father's Stature:___________

Low weight (see text)

SOURCE: Life Expectancy Project (2011)

Mother's Stature:___________ Father's Stature:___________

SOURCE: Life Expectancy Project (2011)

Mother's Stature:___________ Father's Stature:___________

SOURCE: Life Expectancy Project (2011)

Mother's Stature:___________ Father's Stature:___________

Low weight (see text)

SOURCE: Life Expectancy Project (2011)

Mother's Stature:___________ Father's Stature:___________

SOURCE: Life Expectancy Project (2011)

Mother's Stature:___________ Father's Stature:___________

SOURCE: Life Expectancy Project (2011)

Mother's Stature:___________ Father's Stature:___________

Low weight (see text)

SOURCE: Life Expectancy Project (2011)

Mother's Stature:___________ Father's Stature:___________

SOURCE: Life Expectancy Project (2011)

Mother's Stature:___________ Father's Stature:___________

SOURCE: Life Expectancy Project (2011)

Mother's Stature:___________ Father's Stature:___________

Low weight (see text)

SOURCE: Life Expectancy Project (2011)

Mother's Stature:___________ Father's Stature:___________

SOURCE: Life Expectancy Project (2011)

Mother's Stature:___________ Father's Stature:___________

SOURCE: Life Expectancy Project (2011)

Mother's Stature:___________ Father's Stature:___________

Low weight (see text)

SOURCE: Life Expectancy Project (2011)

Mother's Stature:___________ Father's Stature:___________

SOURCE: Life Expectancy Project (2011)

Mother's Stature:___________ Father's Stature:___________

SOURCE: Life Expectancy Project (2011)

Mother's Stature:___________ Father's Stature:___________

Low weight (see text)

SOURCE: Life Expectancy Project (2011)

Mother's Stature:___________ Father's Stature:___________

Mother's Stature:_ Father's Stature:_

Mother's Stature:_ Father's Stature:_

Mother's Stature:_ Father's Stature:_

Mother's Stature:_ Father's Stature:_

Mother's Stature:_ Father's Stature:_

Mother's Stature:_ Father's Stature:_

Mother's Stature:_ Father's Stature:_

Mother's Stature:_ Father's Stature:_

Mother's Stature:_ Father's Stature:_

Mother's Stature:_ Father's Stature:_

Mother's Stature:_ Father's Stature:_

Mother's Stature:_ Father's Stature:_

Mother's Stature:_ Father's Stature:_

Mother's Stature:_ Father's Stature:_

Mother's Stature:_ Father's Stature:_

Mother's Stature:_ Father's Stature:_

Mother's Stature:_ Father's Stature:_

Mother's Stature:_ Father's Stature:_

Mother's Stature:_ Father's Stature:_

Mother's Stature:_ Father's Stature:_

Mother's Stature:_ Father's Stature:_

Mother's Stature:_ Father's Stature:_

Mother's Stature:_ Father's Stature:_

Mother's Stature:_ Father's Stature:_

Mother's Stature:_ Father's Stature:_

Mother's Stature:_ Father's Stature:_

Mother's Stature:_ Father's Stature:_

Mother's Stature:_ Father's Stature:_

Mother's Stature:_ Father's Stature:_

Mother's Stature:_ Father's Stature:_

Mother's Stature:_ Father's Stature:_

Mother's Stature:_ Father's Stature:_

Mother's Stature:_ Father's Stature:_

Mother's Stature:_ Father's Stature:_

Mother's Stature:_ Father's Stature:_

Mother's Stature:_ Father's Stature:_