Republic of the Philippines

Province of Ilocos Sur

MUNICIPALITY OF ALILEM

ALILEM RURAL HEALTH UNIT

NAME: AGE: SEX: CS:

ADDRESS: BDATE: BPLACE:
Date:________________ FOR CHILD AGED 2 MONTHS UP TO 5 YEARS OLD
S> CHECK FOR GENERAL DANGER SIGNS
____ Not able to drink or breastfeed ____lethargic or unconscious
____Vomits everything ____convulsing NOW ____HAD convulsions
HAVE COUGH OR DIFFICULT BREATHING
____ with CHEST INDRAWING _____with STRIDOR ____ with WHEEZING
HAVE DIARRHOEA
____ lethargic or unconscious ____ restless or irritable ___with SUNCKEN EYES
O> ____ with dry skin and skin goes back very slowly when pinched
Bp:_____
T :_____
RR:_____
CR:_____
WT:____
HT:_____
BMI:____

A>

P>

Date:________________ FOR CHILD AGED 2 MONTHS UP TO 5 YEARS OLD

S> CHECK FOR GENERAL DANGER SIGNS
____ Not able to drink or breastfeed ____lethargic or unconscious
____Vomits everything ____convulsing NOW ____HAD convulsions
HAVE COUGH OR DIFFICULT BREATHING
____ with CHEST INDRAWING _____with STRIDOR ____ with WHEEZING
HAVE DIARRHOEA
____ lethargic or unconscious ____ restless or irritable ___with SUNCKEN EYES
O> ____ with dry skin and skin goes back very slowly when pinched
Bp:_____
T :_____
RR:_____
CR:_____
WT:____
HT:_____
BMI:____

A>

P>