TALLY More than 3 seconds -

NAME OF STUDENT: _________________

TOTAL NO. OF FAMILIES SURVEYED: _________ Observe muscle distribution.
Symmetrical -
NO. OF MEMBERS PER FAMILY: asymmetrical -
1. ________
2. _______ Muscle weakness?
3. _________ Yes -
4. . No -
TOTAL NO. OF MALNOURISHED CHILDREN: __________
Delayed and prolonged healing of wounds?
Yes -
Physical Assessment (Signs and Symptoms of No -
Malnutrition)
Presence of edema
Observe eyes for moisture and lesions: Yes. -
Clear - No -
Moist
transparent cornea - Wasted and stunted?
pink palpebral conjunctiva -
others: ________ -

Observe teeth for position and condition. _______

Straight - _________
with no cavities -
others:_________ -
Complete -
Incomplete -

Observe hair texture and color.

Pigmented.
Black hair -
Dry -
Smooth -
Brittle -
Malnutrition Classification (Gomez Classification)
Observed for skin color and texture. Mild -
Smooth - moderate -
Dry - severe -
pink -
turgor present -
others ________ -

Observe nails for color and texture.

firm and pink -
nail clubbing -
others:__________ -

Capillary Refill: Presence of any medical complication?

less than 3 seconds
Pneumonia - diarrhea -
dysentery - severe palmar pallor -
fever - some palmar pallor -
Anemia -