NUTRITIONAL STATUS Baseline: [ ] Endline: [ ] SY: 20___- - 20___

SCHOOL:______________________ DISTRICT:_______________ Grade LEVEL: ______ Section:_________________

Age in Raw Ht. Div. Ht. Raw Nut. Ht.
Birthday mos. Ht./cm. 100 cm. in m2 Wt./kgs. BMI Status Status

1. ________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
2. ________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
3. ________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
4. ________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
5. ________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
6. ________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
7. ________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
8. ________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
9. ________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
10.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
11.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
12.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
13.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
14.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
15.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
16.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
17.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
18.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
19.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
20.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
21.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
22.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
23.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
24.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
25.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
26.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
27.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
28.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
29.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
30.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
31.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
32.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
33.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
34.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
35.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
36.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
37.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
38.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
39.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
40.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
41.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
42.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
43.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
44.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
45.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
46.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
47.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
48.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
49.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
50.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
51.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
52.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
53.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
54.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
55.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
56.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
57.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
58.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
59.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
60.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
Prepared by:
_______________________
Class Adviser
 4 Ps NUTRITIONAL STATUS Baseline: [ ] Endline: [ ] SY: 20___- - 20___

SCHOOL:______________________ DISTRICT:_______________ Grade LEVEL: ______ Section:_________________

Age in Raw Ht. Div. Ht. Raw Nut. Ht.
Birthday mos. Ht./cm. 100 cm. in m2 Wt./kgs. BMI Status Status

1. ________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
2. ________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
3. ________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
4. ________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
5. ________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
6. ________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
7. ________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
8. ________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
9. ________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
10.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
11.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
12.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
13.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
14.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
15.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
16.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
17.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
18.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
19.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
20.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
21.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
22.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
23.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
24.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
25.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
26.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
27.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
28.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
29.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
30.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
31.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
32.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
33.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
34.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
35.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
36.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
37.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
38.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
39.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
40.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
41.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
42.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
43.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
44.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
45.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
46.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
47.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
48.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
49.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
50.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
51.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
52.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
53.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
54.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
55.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
56.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
57.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
58.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
59.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
60.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
Prepared by:
_______________________
Class Adviser
 PWD NUTRITIONAL STATUS Baseline: [ ] Endline: [ ] SY: 20___- - 20___

SCHOOL:______________________ DISTRICT:_______________ Grade LEVEL: ______ Section:_________________

Age in Raw Ht. Div. Ht. Raw Nut. Ht.
Birthday mos. Ht./cm. 100 cm. in m2 Wt./kgs. BMI Status Status

1. ________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
2. ________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
3. ________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
4. ________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
5. ________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
6. ________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
7. ________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
8. ________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
9. ________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
10.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
11.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
12.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
13.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
14.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
15.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
16.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
17.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
18.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
19.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
20.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
21.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
22.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
23.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
24.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
25.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
26.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
27.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
28.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
29.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
30.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
31.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
32.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
33.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
34.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
35.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
36.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
37.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
38.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
39.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
40.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
41.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
42.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
43.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
44.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
45.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
46.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
47.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
48.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
49.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
50.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
51.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
52.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
53.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
54.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
55.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
56.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
57.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
58.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
59.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
60.________________ _______ _____ ______ _____ ______ ______ ______ _____ _____
Prepared by:
_______________________
Class Adviser
NUTRITIONAL STATUS Baseline: [ ] Endline: [ ] SY: 20___- 20___
SCHOOL:______________________ DISTRICT:________________ GRADE Level: ______ Section:___________
Age in Raw Ht. Div. Ht. Raw Nut. Ht.
BOYS: Birthday mos. Ht./cm. 100 cm. in m2 Wt./kgs. BMI Status Stat.

1. ____________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
2. ____________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
3. ____________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
4. ____________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
5. ____________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
6. ____________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
7. ____________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
8. ____________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
9. ____________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
10. ___________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
11. ___________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
12. ___________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
13. ___________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
14. ___________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
15. ___________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
16. ___________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
17. ___________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
18. ___________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
19. ___________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
20. ___________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
21. ___________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
22. ___________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
23. ___________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
24. ___________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
25. ___________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
26. ___________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
27. ___________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
28. ___________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
29. ___________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
30. ___________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
GIRLS:
1. ____________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
2. ____________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
3. ____________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
4. ____________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
5. ____________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
6. ____________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
7. ____________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
8. ____________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
9. ____________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
10. ___________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
11. ___________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
12. ___________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
13. ___________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
14. ___________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
15. ___________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
16. ___________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
17. ___________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
18. ___________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
19. ___________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
20. ___________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
21. ___________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
22. ___________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
23. ___________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
24. ___________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
25. ____________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
26. ____________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
27. ____________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
28. ____________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
29. ____________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
30. ____________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
Prepared by:
_______________________
Class Adviser
4 Ps
NUTRITIONAL STATUS Baseline: [ ] Endline: [ ] SY: 20___- 20___
SCHOOL:______________________ DISTRICT:_____________ GRADE/YEAR Level: ______ Section:___________
Age in Raw Ht. Div. Ht. Raw Nut. Ht.
BOYS: Birthday mos. Ht./cm. 100 cm. in m2 Wt./kgs. BMI Status Stat.

1. ____________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
2. ____________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
3. ____________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
4. ____________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
5. ____________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
6. ____________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
7. ____________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
8. ____________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
9. ____________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
10. ___________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
11. ___________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
12. ___________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
13. ___________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
14. ___________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
15. ___________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
16. ___________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
17. ___________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
18. ___________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
19. ___________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
20. ___________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
21. ___________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
22. ___________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
23. ___________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
24. ___________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
25. ___________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
26. ___________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
27. ___________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
28. ___________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
29. ___________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
30. ___________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
GIRLS:
1. ____________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
2. ____________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
3. ____________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
4. ____________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
5. ____________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
6. ____________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
7. ____________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
8. ____________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
9. ____________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
10. ___________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
11. ___________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
12. ___________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
13. ___________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
14. ___________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
15. ___________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
16. ___________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
17. ___________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
18. ___________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
19. ___________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
20. ___________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
21. ___________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
22. ___________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
23. ___________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
24. ___________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
25. ____________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
26. ____________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
27. ____________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
28. ____________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
29. ____________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
30. ____________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
Prepared by:
_______________________
Class Adviser
PWD
NUTRITIONAL STATUS Baseline: [ ] Endline: [ ] SY: 20___- 20___
SCHOOL:______________________ DISTRICT:_____________ GRADE/YEAR Level: ______ Section:___________
Age in Raw Ht. Div. Ht. Raw Nut. Ht.
BOYS: Birthday mos. Ht./cm. 100 cm. in m2 Wt./kgs. BMI Status Stat.

1. ____________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
2. ____________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
3. ____________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
4. ____________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
5. ____________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
6. ____________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
7. ____________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
8. ____________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
9. ____________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
10. ___________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
11. ___________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
12. ___________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
13. ___________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
14. ___________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
15. ___________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
16. ___________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
17. ___________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
18. ___________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
19. ___________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
20. ___________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
21. ___________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
22. ___________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
23. ___________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
24. ___________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
25. ___________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
26. ___________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
27. ___________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
28. ___________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
29. ___________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
30. ___________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
GIRLS:
1. ____________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
2. ____________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
3. ____________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
4. ____________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
5. ____________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
6. ____________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
7. ____________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
8. ____________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
9. ____________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
10. ___________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
11. ___________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
12. ___________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
13. ___________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
14. ___________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
15. ___________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
16. ___________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
17. ___________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
18. ___________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
19. ___________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
20. ___________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
21. ___________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
22. ___________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
23. ___________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
24. ___________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
25. ____________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
26. ____________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
27. ____________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
28. ____________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
29. ____________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
30. ____________________ _______ _____ ______ _____ ______ ______ ______ _____ ____
Prepared by:
_______________________
Class Adviser
NUTRITIONAL STATUS: ( ) Baseline ( ) Endline SY: 20____ - 20____
School:__________________ District:______________ Grade:_____ Section:______________
Enrolment: No.: Male:______ Female:______

BOYS:

1._________________________
Ht.S NS
Yy mm dd _____cm. div.by 100= ____ m. _____ BMI=_____kgs.
X ____ ______m2
DW: Ht. =________m2 BMI= ________ ____
- DB : _________________________ or _______
____ yrs. ____mos. ____days
____ X 12 = _____mo.+ ____mo.= ______ mos.

2._________________________
Ht.S NS
DW: _____cm. div.by 100=____ m. _____ BMI= _____kgs.
- DB: __________________________ X____ ______m2
____yrs. ____mos. ____days Ht. = _______ m2 BMI= _______ ____
____ X 12 = _____mo.+ ____mo. = ______mos. or_______

3._________________________
Ht.S NS
DW: _____cm. div.by 100= _____ m. _____ BMI= _____kgs.
-BD : ___________________________ X_____ ______m2
____yrs. ____mos. _____days Ht. = ______m2 BMI= _______ ____
____ X 12 = ____mo. + ____mo. = ______mos. or ______

4._________________________
Ht.S NS
DW: _____cm. div.by 100= _____ m. _____ BMI= _____kgs.
- DB: ___________________________ X_____ ______m2
____yrs. ____mos. _____days Ht. = ______m2 BMI= _______ ____
____ X 12= _____mo. + ___mos. = ______mos. or ______

5._________________________
Ht.S NS
DW: _____cm div.by 100= _____ m. _____ BMI= _____kgs.
-DB: ____________________________ X_____ ______m2
____yrs. ____mos. _____days Ht. = ______m2 BMI= _______ ____
____X 12 =_____mo. + ____mos.= ______mos. or______

6._________________________
Ht.S NS
DW : _____cm. div.by 100=_____ m. _____ BMI=______kgs.
-DB : _____________________________ X_____ ______m2
_____yrs. ____mos. _____days Ht. = ______m2 BMI= _______ ____
____ X 12 = _____mo. + ____mos.= _____mos. or ______

7._________________________
Ht.S NS
DW : _____cm.div.by 100= _____ m. _____ BMI=_____kgs.
-DB : ____________________________ X_____ ______m2
_____yrs. ____mos. _____days Ht. = ______m2 BMI=______ ____
____X 12= _____mo. + ____mos.= ______mos. or______

8._________________________
Ht.S NS
DW: _____cm. div.by 100= ____ m. _____ BMI=_____ kgs.
-DB : ____________________________ X_____ ______m2
____yrs. ____mos. _____days Ht. = ______m2 BMI=_______ ____
____ X 12 = _____mo. + ____mos. = ____mos. or______
9._________________________
Ht.S NS
DW: _____cm. div.by 100=_____ m. _____ BMI= _____kgs.
- DB: __________________________ X_____ ______m2
____yrs. ____mos. ____days Ht. = ______ m2 BMI= ______ ____
____X 12 = _____mo.+ ____mo. = ______mos. or_______

10.________________________
Ht.S NS
DW: _____cm. div.by 100=_____ m. _____ BMI= ______kgs.
-DB: __________________________ X_____ _______m2
____yrs. ____mos. ____days Ht.= ______m2 BMI= ______ ____
____X 12=_____mo.+ ____mo. = _______mos. or_______

11,_______________________ Ht.S NS
_____cm. div.by 100= ____ m. _____ BMI=_____kgs.
X ____ ______m2
DW: Ht. =________m2 BMI= ________ ____
- DB : _________________________ or _______
____ yrs. ____mos. ____days
____ X 12 = _____mo.+ ____mo.= ______ mos.

12._______________________
Ht.S NS
DW: _____cm. div.by 100=____ m. _____ BMI= _____kgs.
- DB: __________________________ X____ ______m2
____yrs. ____mos. ____days Ht. = _______ m2 BMI= _______ ____
____ X 12 = _____mo.+ ____mo. = ______mos. or_______

13._______________________
Ht.S NS
DW: _____cm. div.by 100= _____ m. _____ BMI= _____kgs.
-BD : ___________________________ X_____ ______m2
____yrs. ____mos. _____days Ht. = ______m2 BMI= _______ ____
____ X 12 = ____mo. + ____mo. = ______mos. or ______

14._______________________
Ht.S NS
DW: _____cm. div.by 100= _____ m. _____ BMI= _____kgs.
- DB: ___________________________ X_____ ______m2
____yrs. ____mos. _____days Ht. = ______m2 BMI= _______ ____
____ X 12= _____mo. + ___mos. = ______mos. or ______

15._______________________
Ht.S NS
DW: _____cm div.by 100= _____ m. _____ BMI= _____kgs.
-DB: ____________________________ X_____ ______m2
____yrs. ____mos. _____days Ht. = ______m2 BMI= _______ ____
____X 12 =_____mo. + ____mos.= ______mos. or______

16._______________________
Ht.S NS
DW : _____cm. div.by 100=_____ m. _____ BMI=______kgs.
-DB : _____________________________ X_____ ______m2
_____yrs. ____mos. _____days Ht. = ______m2 BMI= _______ ____
____ X 12 = _____mo. + ____mos.= _____mos. or ______

17._______________________
Ht.S NS
DW : _____cm.div.by 100= _____ m. _____ BMI=_____kgs.
-DB : ____________________________ X_____ ______m2
_____yrs. ____mos. _____days Ht. = ______m2 BMI=______ ____
____X 12= _____mo. + ____mos.= ______mos. or______
18.._________________________
Ht.S NS
DW: _____cm. div.by 100=_____ m. _____ BMI= _____kgs.
- DB: __________________________ X_____ ______m2
____yrs. ____mos. ____days Ht. = ______ m2 BMI= ______ ____
____X 12 = _____mo.+ ____mo. = ______mos. or_______

19.________________________
Ht.S NS
DW: _____cm. div.by 100=_____ m. _____ BMI= ______kgs.
-DB: __________________________ X_____ _______m2
____yrs. ____mos. ____days Ht.= ______m2 BMI= ______ ____
____X 12=_____mo.+ ____mo. = _______mos. or_______

20,_______________________ Ht.S NS
_____cm. div.by 100= ____ m. _____ BMI=_____kgs.
X ____ ______m2
DW: Ht. =________m2 BMI= ________ ____
- DB : _________________________ or _______
____ yrs. ____mos. ____days
____ X 12 = _____mo.+ ____mo.= ______ mos.

21._______________________
Ht.S NS
DW: _____cm. div.by 100=____ m. _____ BMI= _____kgs.
- DB: __________________________ X____ ______m2
____yrs. ____mos. ____days Ht. = _______ m2 BMI= _______ ____
____ X 12 = _____mo.+ ____mo. = ______mos. or_______

22._______________________
Ht.S NS
DW: _____cm. div.by 100= _____ m. _____ BMI= _____kgs.
-BD : ___________________________ X_____ ______m2
____yrs. ____mos. _____days Ht. = ______m2 BMI= _______ ____
____ X 12 = ____mo. + ____mo. = ______mos. or ______

23._______________________
Ht.S NS
DW: _____cm. div.by 100= _____ m. _____ BMI= _____kgs.
- DB: ___________________________ X_____ ______m2
____yrs. ____mos. _____days Ht. = ______m2 BMI= _______ ____
____ X 12= _____mo. + ___mos. = ______mos. or ______

24._______________________
Ht.S NS
DW: _____cm div.by 100= _____ m. _____ BMI= _____kgs.
-DB: ____________________________ X_____ ______m2
____yrs. ____mos. _____days Ht. = ______m2 BMI= _______ ____
____X 12 =_____mo. + ____mos.= ______mos. or______

25._______________________
Ht.S NS
DW : _____cm. div.by 100=_____ m. _____ BMI=______kgs.
-DB : _____________________________ X_____ ______m2
_____yrs. ____mos. _____days Ht. = ______m2 BMI= _______ ____
____ X 12 = _____mo. + ____mos.= _____mos. or ______

26._______________________
Ht.S NS
DW : _____cm.div.by 100= _____ m. _____ BMI=_____kgs.
-DB : ____________________________ X_____ ______m2
_____yrs. ____mos. _____days Ht. = ______m2 BMI=______ ____
____X 12= _____mo. + ____mos.= ______mos. or______
27._________________________
Ht.S NS
DW: _____cm. div.by 100=_____ m. _____ BMI= _____kgs.
- DB: __________________________ X_____ ______m2
____yrs. ____mos. ____days Ht. = ______ m2 BMI= ______ ____
____X 12 = _____mo.+ ____mo. = ______mos. or_______

28.________________________
Ht.S NS
DW: _____cm. div.by 100=_____ m. _____ BMI= ______kgs.
-DB: __________________________ X_____ _______m2
____yrs. ____mos. ____days Ht.= ______m2 BMI= ______ ____
____X 12=_____mo.+ ____mo. = _______mos. or_______

29,_______________________ Ht.S NS
_____cm. div.by 100= ____ m. _____ BMI=_____kgs.
X ____ ______m2
DW: Ht. =________m2 BMI= ________ ____
- DB : _________________________ or _______
____ yrs. ____mos. ____days
____ X 12 = _____mo.+ ____mo.= ______ mos.

30._______________________
Ht.S NS
DW: _____cm. div.by 100=____ m. _____ BMI= _____kgs.
- DB: __________________________ X____ ______m2
____yrs. ____mos. ____days Ht. = _______ m2 BMI= _______ ____
____ X 12 = _____mo.+ ____mo. = ______mos. or_______

31._______________________
Ht.S NS
DW: _____cm. div.by 100= _____ m. _____ BMI= _____kgs.
-BD : ___________________________ X_____ ______m2
____yrs. ____mos. _____days Ht. = ______m2 BMI= _______ ____
____ X 12 = ____mo. + ____mo. = ______mos. or ______

32._______________________
Ht.S NS
DW: _____cm. div.by 100= _____ m. _____ BMI= _____kgs.
- DB: ___________________________ X_____ ______m2
____yrs. ____mos. _____days Ht. = ______m2 BMI= _______ ____
____ X 12= _____mo. + ___mos. = ______mos. or ______

33._______________________
Ht.S NS
DW: _____cm div.by 100= _____ m. _____ BMI= _____kgs.
-DB: ____________________________ X_____ ______m2
____yrs. ____mos. _____days Ht. = ______m2 BMI= _______ ____
____X 12 =_____mo. + ____mos.= ______mos. or______

34._______________________
Ht.S NS
DW : _____cm. div.by 100=_____ m. _____ BMI=______kgs.
-DB : _____________________________ X_____ ______m2
_____yrs. ____mos. _____days Ht. = ______m2 BMI= _______ ____
____ X 12 = _____mo. + ____mos.= _____mos. or ______

35._______________________
Ht.S NS
DW : _____cm.div.by 100= _____ m. _____ BMI=_____kgs.
-DB : ____________________________ X_____ ______m2
_____yrs. ____mos. _____days Ht. = ______m2 BMI=______ ____
____X 12= _____mo. + ____mos.= ______mos. or______
NUTRITIONAL STATUS: ( ) Baseline ( ) Endline SY: 20____ - 20____
School:__________________ District:______________ Grade:_____ Section:______________
Enrolment: No.: Male:______ Female:______

GIRLS:

1._________________________
Ht.S NS
Yy mm dd _____cm. div.by 100= ____ m. _____ BMI=_____kgs.
X ____ ______m2
DW: Ht. =________m2 BMI= ________ ____
- DB : _________________________ or _______
____ yrs. ____mos. ____days
____ X 12 = _____mo.+ ____mo.= ______ mos.

2._________________________
Ht.S NS
DW: _____cm. div.by 100=____ m. _____ BMI= _____kgs.
- DB: __________________________ X____ ______m2
____yrs. ____mos. ____days Ht. = _______ m2 BMI= _______ ____
____ X 12 = _____mo.+ ____mo. = ______mos. or_______

3._________________________
Ht.S NS
DW: _____cm. div.by 100= _____ m. _____ BMI= _____kgs.
-BD : ___________________________ X_____ ______m2
____yrs. ____mos. _____days Ht. = ______m2 BMI= _______ ____
____ X 12 = ____mo. + ____mo. = ______mos. or ______

4._________________________
Ht.S NS
DW: _____cm. div.by 100= _____ m. _____ BMI= _____kgs.
- DB: ___________________________ X_____ ______m2
____yrs. ____mos. _____days Ht. = ______m2 BMI= _______ ____
____ X 12= _____mo. + ___mos. = ______mos. or ______

5._________________________
Ht.S NS
DW: _____cm div.by 100= _____ m. _____ BMI= _____kgs.
-DB: ____________________________ X_____ ______m2
____yrs. ____mos. _____days Ht. = ______m2 BMI= _______ ____
____X 12 =_____mo. + ____mos.= ______mos. or______

6._________________________
Ht.S NS
DW : _____cm. div.by 100=_____ m. _____ BMI=______kgs.
-DB : _____________________________ X_____ ______m2
_____yrs. ____mos. _____days Ht. = ______m2 BMI= _______ ____
____ X 12 = _____mo. + ____mos.= _____mos. or ______

7._________________________
Ht.S NS
DW : _____cm.div.by 100= _____ m. _____ BMI=_____kgs.
-DB : ____________________________ X_____ ______m2
_____yrs. ____mos. _____days Ht. = ______m2 BMI=______ ____
____X 12= _____mo. + ____mos.= ______mos. or______

8._________________________
Ht.S NS
DW: _____cm. div.by 100= ____ m. _____ BMI=_____ kgs.
-DB : ____________________________ X_____ ______m2
____yrs. ____mos. _____days Ht. = ______m2 BMI=_______ ____
____ X 12 = _____mo. + ____mos. = ____mos. or______
9._________________________
Ht.S NS
DW: _____cm. div.by 100=_____ m. _____ BMI= _____kgs.
- DB: __________________________ X_____ ______m2
____yrs. ____mos. ____days Ht. = ______ m2 BMI= ______ ____
____X 12 = _____mo.+ ____mo. = ______mos. or_______

10.________________________
Ht.S NS
DW: _____cm. div.by 100=_____ m. _____ BMI= ______kgs.
-DB: __________________________ X_____ _______m2
____yrs. ____mos. ____days Ht.= ______m2 BMI= ______ ____
____X 12=_____mo.+ ____mo. = _______mos. or_______

11,_______________________ Ht.S NS
_____cm. div.by 100= ____ m. _____ BMI=_____kgs.
X ____ ______m2
DW: Ht. =________m2 BMI= ________ ____
- DB : _________________________ or _______
____ yrs. ____mos. ____days
____ X 12 = _____mo.+ ____mo.= ______ mos.

12._______________________
Ht.S NS
DW: _____cm. div.by 100=____ m. _____ BMI= _____kgs.
- DB: __________________________ X____ ______m2
____yrs. ____mos. ____days Ht. = _______ m2 BMI= _______ ____
____ X 12 = _____mo.+ ____mo. = ______mos. or_______

13._______________________
Ht.S NS
DW: _____cm. div.by 100= _____ m. _____ BMI= _____kgs.
-BD : ___________________________ X_____ ______m2
____yrs. ____mos. _____days Ht. = ______m2 BMI= _______ ____
____ X 12 = ____mo. + ____mo. = ______mos. or ______

14._______________________
Ht.S NS
DW: _____cm. div.by 100= _____ m. _____ BMI= _____kgs.
- DB: ___________________________ X_____ ______m2
____yrs. ____mos. _____days Ht. = ______m2 BMI= _______ ____
____ X 12= _____mo. + ___mos. = ______mos. or ______

15._______________________
Ht.S NS
DW: _____cm div.by 100= _____ m. _____ BMI= _____kgs.
-DB: ____________________________ X_____ ______m2
____yrs. ____mos. _____days Ht. = ______m2 BMI= _______ ____
____X 12 =_____mo. + ____mos.= ______mos. or______

16._______________________
Ht.S NS
DW : _____cm. div.by 100=_____ m. _____ BMI=______kgs.
-DB : _____________________________ X_____ ______m2
_____yrs. ____mos. _____days Ht. = ______m2 BMI= _______ ____
____ X 12 = _____mo. + ____mos.= _____mos. or ______

17._______________________
Ht.S NS
DW : _____cm.div.by 100= _____ m. _____ BMI=_____kgs.
-DB : ____________________________ X_____ ______m2
_____yrs. ____mos. _____days Ht. = ______m2 BMI=______ ____
____X 12= _____mo. + ____mos.= ______mos. or______