BNS Form No.

3A
Philippine Plan of Action for Nutrition

MONTHLY RECORD OF WEIGHT AND WEIGHT STATUS

INFANTS 0-23 MONTHS

PROVINCE CITY/ MUNICIPALITY

Date of Weighing: Date of Weighing: Date of Weighing: Date of Weighing: Date of Weighing: Date of Weighing:
DATE OF BIRTH
No. NAME OF CHILD
Age Weight Weight Age Weight Weight Age Weight Weight Age Weight Weight Age Weight Weight Age Weight Weight
Year Mo. Day months (Kgs) Status months (Kgs) Status months (Kgs) Status months (Kgs) Status months (Kgs) Status months (Kgs) Status

NO. OF SEVERELY UNDERWEIGHT: DATE ACCOMPLISHED:

NO. OF UNDERWEIGHT: DATE ACCOMPLISHED: