OFFICE OF THE HEALTH

OPT, VITAMIN A & DEWORMING MASTERLIST

INDIGENOU DATE ACTUAL AGE VITAMIN LAST DEWORMING LAST
N CHILD’S NAME MOTHER’S S OF DATE WEIGHT HEIGH IN A DATE DATE DATE
O NAME PRESCHOOL BIRTH OF T MONTHS DATE GIVEN GIVEN GIVEN
CHILD? WEIGHIN as of GIVEN
YES/NO G