Date:
Dear parent / guardian of:
Your child’s height and weight were recently screened to assess any concern for nutrition risk. Below
are the most current measurements:
date
height
weight
BMI
According to these measurements, your child’s BMI (a ratio of height and weight) was indicated to be
below the 5th percentile. This means that your child’s measurements are within the lowest 5% of
children at their age. This may indicate that there is a risk for nutritional concern.




It is asked that you please visit your health care provider for additional evaluation and have
your child’s physician fill out the action plan form which is attached to this document.
The action plan form must be returned to your Head Start site.
For additional information, please follow up with your site’s dietitian or visit your WIC center
nutritionist.
Please read the attached materials.
For more information, please speak with your Head Start staff.
Sincerely,
[your site information here]
(updated 2015)
5th
Date:
Child’s name:
Parent’s Name:
This child who is enrolled in our Head Start program was flagged due to their weight indicating possible
nutrition risk. Below are the most current measurements:
date
height
weight
BMI
According to these measurements this child is indicated to be below the 5th percentile. This may
indicate that there is a risk for nutritional concern and it is asked that there be documentation of a
treatment plan if needed.

It is asked that you (the physician) please evaluate this child to determine if there is any
physiologic, metabolic or other concern contributing to their measurements.

Please fill out the attached action plan document for the parent to indicate what course of
action should be taken.

Please return the form to the parent to the Head Start site.
The Head Start site will reinforce the recommendations provided.
Thank you for your cooperation,
[your site information here]
(updated 2015)
5th
Medical Provider Action Plan for Nutrition Concern
date:
to be filled out by child’s physician
child’s name
parent’s name
1. Is there a metabolic or physiological concern at this time?
 yes  no
2. The medical evaluation has determined that this child is at risk of:
 underweight
 overweight
 weight is not of concern at this time
3. Intervention
 dietitian / nutritionist referral
 referral to WIC
 other:
 nutrition supplementation, dietary modification recommendations for child at school:
4. Dietary recommendations for child
 Manage fluids to improve appetite and food intake:
● Encourage a gradual change in fluid consumption to approximately 16-24 oz whole milk or other
calcium fortified, nutrient dense beverage.
● Together, juice, fruit drinks and soda should be limited to 4 oz/day. Avoid beverages which
provide sugar as the main nutrient.
 Increase calories in diet. Try adding:
● Avocados, butter, oils, whole milk, cream, half and half, powdered milk, full-fat yogurts, sour
cream, peanut butter, instant breakfast, protein powders
● Other foods recommended:
 Enjoy family meals:
● Parents should role model healthy eating behaviors and eating foods during mealtimes.
● Establish routines around mealtimes and snacks (Offer 3 meals and 2 snacks everyday)
● Be sure to allow children enough time at the table. Aim for at least 20 minutes.
● Try to make meals stress-free. Avoid lecturing or forcing children to eat.
5. Additional recommendations:
6. Follow-up appointment date:
healthcare provider signature
healthcare provider name, title, printed
address
phone
(updated 2015)
date
fax
email
5th