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SAINT LOUIS UNIVERSITY

SCHOOL OF MEDICINE
DEPARTMENT OF FAMILY AND COMMUNITY MEDICINE

DATA CAPTURE FORM


SCHOOL: _______________________________________________ CONTROL NO -

DATE (MM-DD-YYYY) SEX


0 7 - - 2 0 1 9 M F

FAMILY NAME

GIVEN NAME

MIDDLE NAME AGE DATE OF BIRTH (MM-DD-YYYY)


- -

CITY ADDRESS

FATHER’S NAME CONTACT NUMBER

MOTHER’S NAME CONTACT NUMBER

GUARDIAN RELATIONSHIP TO CHILD CONTACT NUMBER

ANTHROPOMETRIC DATA
HEIGHT WEIGHT BMI

_____ cm _____ kg _____ kg/m2

Ht for age Wt for age Wt for ht BMI for age


¨ Very tall ¨ Obese ¨ Obese ¨ Obese
¨ Normal ¨ Overweight ¨ Overweight ¨ Overweight
¨ Stunted ¨ Risk ¨ Risk ¨ Risk
¨ Severely stunted ¨ Normal ¨ Normal ¨ Normal
¨ Wasted ¨ Wasted ¨ Wasted
¨ Severely wasted ¨ Severely wasted ¨ Severely wasted
PHYSICAL EXAMINATION
( ) scars, ( ) blisters, ( ) discolorations, ( ) webbed neck, ( ) congenital defects, ( ) torticollis,
NECK
( ) fixed/movable masses, ( ) midline trachea
THYROID ( ) smooth and fleshy, ( ) visible neck mass, ( ) palpable neck mass, ( ) firm, ( ) bruit, ( ) pain
PALLOR ( ) none, ( ) some, ( ) very pale
OTHER FINDINGS

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