AMPATH Pediatric Nutrition Encounter Form
v2.0
Date: _ _/_ _/_ _ _
Name:
AMRS ID:
Date of Birth:_ _/_ _/_ _ _ _
District:
AMPATH ID:
If Birth date Unknown, Age at last Birthday:_ _ _ _
Location:
Sex: □ M □ F
Sub location:
Encounter Clinic:_ ___________________Module(Where applicable)______________
Visit Type:
□ New □ Return □ Readmission (Defaulted Patient) □ Relapse (Recurrence after delivery and discharge)
1. HIV Disclosure Status:
2. HIV Status :□ HIV-Positive
Disclosed to: □ No one □ Peer □ Other, Specify:_________
□ HIV-Negative □ Unknown HIV Status
3.Nutritional assessment
3a. Anthropometric assessment
Height/ Length: _ _ _ ._(cm) Wt: _ _._ (kg)
Red Flag
Head Circumference :_ _ _._ W/H z-scores _ _._
□ Severe wastage: <-3 W/H Z-scores
BMI for Age z-scores _ _._ MUAC: _ _._ (cm)
□ Mild/ Moderate Wastage: < -2 W/H Z-scores
Demispan (for bedridden patients): _ _ _._ (cm)
Estimated Height from demispan: _ _ _._ (cm)
b. Revisiting patients
Red Flag
Weight: □ Gained □ Static □ Lost
Weight Loss or gain of >10% of in the last month
MUAC: □ Gained □ Static □ Lost
4. Biochemical assessment
3a. Last HB Recorded:________________
b. Last CD4 Recorded: _ _ _ Date: _ _/_ _/_ _
Date: _ _/_ _/_ _ _ _ To be updated from amrs
To be updated from amrs.
CD4 <200? □Yes □No not stored
5. Physical Assessment
5a. Any clinical signs/symptoms that may warrant nutrition attention?
□ Hair □ Eyes □ Nails
□ Thyroid gland □ Mouth □ Skin □ Other(Specify): ______________
b.Vitamin A Supplement given in the last 6 months?
c. Dewormed in the last 6 months?
□Yes □No
□Yes □No
Dietary assessment
6. Quantity
6a. Is the child currently breastfeeding?
b. Is the child on replacement feeding? □Yes □ No
□Yes □No
c. AFASS Criteria Met: □Yes □ No
(i) Who prepares meals for you? □ Self
□ Family member □ Other __________________
(ii) Is uji consumed in your Household? □ Yes
□ No
(iii) In the Last 3 days, have you missed a meal because there was not enough food in the house?
□Yes □No
(iv) In the Last 3 days, has anyone in your Household missed a meal because there was not
enough food?
□Yes □No
(v) In the Last 3 days, did you go to bed hungry?
□Yes □No
(vi) In the last 3 days, did anyone in your household go to bed hungry?
□Yes □No
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7a. In the last 3 days have you eaten any of the following foods? *Note: Frequency refers to number of times that the food
was consumed as a meal in the last 3 days
Food
Frequency
Food
Frequency
Carbohydrates:
□ Carbohydrates, Grains
□ Carbohydrates, Roots
Ugali, rice, bread, chapatti,
Frequency___________ Sweet Potatoes, yams,
Frequency____________
noodles or any other foods made
potatoes, Cassava,
from millet, sorghum, maize, rice,
Arrowroot, other foods made
wheat or other grains
from roots or tubers
Proteins:
□ Proteins, Meat
□ Proteins, Fish
Meat: Goat, sheep, pork, rabbit,
Frequency___________ Fish: Any fresh or dried fish or Frequency____________
wild game, chicken, duck, other
shell fish
birds, liver, kidney, heart, or other
organ meats
□ Proteins, Beans
□ Proteins, Dairy
Beans, peas lentils or nuts
Frequency___________ Milk, cheese, yogurt, or other Frequency____________
milk products
□ Vegetables
□ Fruits
Sukuma wiki, spinach, managu,
Frequency___________ Banana, Pineapple, Orange,
Frequency____________
kienyeji, tomatoes, cabbage,
Mango, Apple or other fruits
carrots, pumpkin, other leafy
greens, or vegetables
□ Sugar/Honey
Frequency___________ □ Other Foods
Frequency____________
Coffee, tea, condiments?
7b. Food Quality: □Adequate □ Inadequate
*Note: Inadequate quality: Eating less than 3 protein rich foods and less than 3 vegetable/fruit foods in 3 days.
c. Food Access: □Adequate □ Inadequate
*Note: Inadequate: If there is Inadequate Quantity or Quality of food, Adequate: If there is adequate quantity or quality of food.
d. Is inadequacy of food quality due to food access rather than food preference? □Yes □No
8. Nutrition diagnosis
8a. Appetite test; for severely malnourished patients *Passed: able to feed ≥ 1 sachet(s) of RUTF during the test.
□ Passed □ Failed
b. Risk of Refeeding syndrome: □High □Low
*Note: High If the patient has had no food or poor food intake in the last 5-10days: If high, refer patient for stabilization/to the
clinician or doctor.
c. Uncontrolled barriers to food intake
□ Nausea □Vomiting □ Diarrhea □Constipation □Difficulty in chewing □ Difficulty in swallowing □Fatigue □Heartburn □Lack of
appetite □Food allergies □ Others
9. Nutrition intervention decision matrix
9a. Are the patient’s parents/guardian in the food program? □Yes
b. Does patient meet criteria for nutrition support:
□No
□Yes □No
c. Is patient willing to use therapeutic/supplemental food? □Yes □No
d. If no, provide reason: □ Does not like taste □ Causes nausea □Too Sweet
□ Contradiction To Current Health Condition.
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Client category
Wasting criteria
Age group 6-23mo
W/H Z-Score: <-2 or
MUAC 11.5-12.0cm
W/H Z-Score: <-3 or
MUAC <11.5
Age group 2459mo
Age group 5-9 yrs
Ages 10-14yrs
Ages 15-17yrs
Nutrition
Classification
□ Moderate
Food Prescribed/Plan
□ SF______Servings
Other Food prescription
options
First food:_____gm
□ Severe
□ RUTF______Sachets
First food:______Sachets
W/H Z-Score: <-2 or
MUAC 11.5-13.5cm
□ Moderate
□ SF_______Servings
First food:_____ gm
W/H Z-Score: <-3 or
MUAC <11.5
BMI/Age Z-Score: <-2
or MUAC 13.5-14.5 cm
□ Severe
□ CSB______Kgs
□ RUTF______Sachets
First food:_____ gm
□ Moderate
□ CSB______Kgs
□ SF_______Servings
First food:_____ gm
BMI/Age Z-Score: <3or MUAC <13.5
□ Severe
□ CSB_______Kgs
□ RUTF______Sachets
BMI/Age Z-Score: <-2
or MUAC 14-18.5cm
□ Moderate
□ CSB______Kgs
□ CSB______Kgs
□ Severe
□ RUTF______Sachets
BMI/Age Z-Score: <-3
or MUAC <14.5
10. Referred to: □ Social work
11. Return to clinic date:
□ FBF (Foundation plus):
□ CSB______Kgs
□ FPI □ Legal □ Psychosocial
Nutritionist Name:
□ FBF (Foundation plus):
_________Sachets
_________Sachets
□ FBF (Foundation plus):
_________Sachets
□ Others Specify_______
Provider Code _ _ _-_
AFASS:, Acceptable, feasible, Affordable, Sustainable, Safe
Maize, beans, vegetable oil
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SF (Supplementary feeding):