Orphans and Vulnerable Children - CRIN

Child Health Monitoring Sheet

Handout 5 - Module 3 Topic 3

FOR QUARTERLY MONITORING

Child’s Name: ______________________________________ ID No. ________________

Male Female

Community / Village: _________________________________________________________

Parish / Location / Division: ___________________________________________________

Guardian’s Name: ___________________________________________________________

Guardian’s Signature: _________________________________________________________

Child’s Health Record:

1 Height (m): __________________________ 2 Weight (Kg): _____________________

3 Age ________________ (In years, but if less than five years old, quote in months)

4 Immunisation Status (for only children under 60 months):

DPT+ BCG DPT2+ DPT3+

OPV0 OPV1 OPV2 OPV3 Measles

5 Did the child fall sick in the last 3 months? (i.e. since the last WV health check-up)

Yes No If yes, explain:

(a) Type of sickness: ___________________________________________________________

(b) Action taken: ______________________________________________________________

General Health Observations:

Head (observe hair, teeth, eyes and ears):

(a) Hair: Normal Abnormal If abnormal, explain: ________________________

___________________________________________________________________________

(b) Teeth: Normal Abnormal If abnormal, explain: ________________________

___________________________________________________________________________

(c) Eyes: Normal Abnormal If abnormal, explain: ________________________

___________________________________________________________________________

Body (observe arms, legs and feet for skin disorders, wounds etc.):

Normal Abnormal If abnormal, explain: _____________________________

___________________________________________________________________________

7 Overall comments or actions to be taken: _________________________________________

___________________________________________________________________________

Date: _______________________________________________________________________

Form filled in by: ________________________________________ Title: ________________

ADP Name: _________________________________________ ADP No.: _______________

Adopted from EAR-NO ADP Sponsorship monitoring child management, 2004

Guide to Mobilising and Strengthening Community-Led Care for Orphans and Vulnerable Children Appendix 1, Handouts^333