NAME Date Of Birth NUTRITIONAL STATUS

Actual Date of Pantawid Member (pls PWD (pls. IP Child

No. Address Name of Mother Sex Weighing / weight height Age in Weight for Height for specify RCCT/4p's or MCCT put check (pls. put
First Name Middle Name Last Name month day year Measuring (kg) (cm) months Weight for Height Age Status and indicate reference mark) check
(mm/dd/yyyy) Age Status number) mark)
(Wasting) (Stunting)

4 ALMAGUER NORTH 6/17/2022

5 ALMAGUER SOUTH 6/17/2022

7 BARAT 6/17/2022

8 BUAG 6/17/2022

10 DULLAO 6/17/2022

13 MABUSLO 6/17/2022

14 MACATE 6/17/2022

16 MANAMTAM 6/17/2022

19 PALLAS 6/17/2022

20 SALICPAN 6/17/2022
 Child of
Solo
Parent (pls
put check
mark)
 UNDERWEIGHT
(Weight-for-Age)

No.
Name of Child No. of Underwe Severely Overwei
Development Centers Beneficiries Normal Underwe
(N) ight ight ght TOTAL
(UW) (OW)
(SUW)

1 ABIAN 1 1
2 ABINGANAN 1 1
3 ALIAGA 1 1
4 ALMAGUER NORTH 1
5 ALMAGUER SOUTH 1
6 BANGGOT 1 1
7 BARAT 1
8 BUAG 1
9 CALAOCAN 1 1
10 DULLAO 1
11 HOMESTEAD 1 1
12 INDIANA 1 1
13 MABUSLO 1
14 MACATE 1
15 MAGSAYSAY HILL 1 1
16 MANAMTAM 1
17 MAUAN 1 1
18 ORANG 1
19 PALLAS 1
20 SALICPAN 1
21 SALINAS 1 1
22 SAN ANTONIO NORTH 1 1
23 SAN ANTONIO SOUTH 1
24 SAN FERNANDO 1 1
25 SAN LEONARDO 1 1
26 STO. DOMINGO PROPER 1 1
27 STO. DOMINGO WEST 1 1
28 UPPER BATU 1 1
 WASTING STUNTING
(Weight-for-Height) (Height-for-Age)

Severely Overwei Severely

Normal Wasted Obese Normal Stunted Tall
(N) (W) Wasted ght (O) TOTAL (N) (S) Stunted (T)
(SW) (OW) (SS)

1 1
1 1
1 1

1 1

1 1

1 1
1 1

1 1

1 1

1 1
1 1

1 1
1 1
1 1
1 1
1 1
Age)

TOTAL
 CHILDREN AGE
NO DCC NAME
CDC SNP TOTAL 1 2 3 4
1 ABIAN 1
2 ABINGANAN 1
3 ALIAGA 1
4 ALMAGUER NORTH
5 ALMAGUER SOUTH
6 BANGGOT 1
7 BARAT
8 BUAG
9 CALAOCAN 1
10 DULLAO
11 HOMESTEAD 1
12 INDIANA 1
13 MABUSLO
14 MACATE
15 MAGSAYSAY HILL 1
16 MANAMTAM
17 MAUAN 1
18 ORANG 1
19 PALLAS
20 SALICPAN
21 SALINAS 1
22 SAN ANTONIO NORTH 1
23 SAN ANTONIO SOUTH 1
24 SAN FERNANDO 1
25 SAN LEONARDO 1
26 STO. DOMINGO PROPER 1
27 STO. DOMINGO WEST 1
28 UPPER BATU 1
29 NCDC 2 2 2
GE GENDER UTILIZATION
4 P's I P's CWD's
5 TOTAL M F TOTAL (based
1
1
1

1
1

1
1

1
1
1
1
1
1
1
1
3 3