Child Assessment Form

SOS Village, Revenue Society

Name

Age

Height

Weight

Medical Condition (if any)

Clinical Signs & Symptoms

Hair (brittle, rough, wire like, hair fall) Muscle weakness

Nails (spoon shaped, discolored, smooth) Tongue (sores, deep red, swollen, smooth)

Teeth (cavity, loss of tooth, discoloration) Eyes (pale, sunken, dry membranes)

Skin (dry, pale, scaly, patchy)

Gastrointestinal Signs & Symptoms

Acidity Diarrhea
Constipation Heart burn
Nausea

Growth Percentile According to Data

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Recommendation

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