Republicof the PHILIPPINES

Department of Health
NATIONAL NUTRITION COUNCIL

MASTERLIST OF CHILDREN AGED 0 TO 23 MONTHS

Year : ___________________ Region: _____________________ Province: _____________________________ City/Municipality: ___________________

Barangay : ___________________ Purok/Sitio (if applicable) _____

Name of Date of Baseline Nutritional Status

Address Name of Child
Mother/Father/Caregiver Birth as of __________________
Contact Number of
Child seq. Age in
Father/Mother/ Weight for
Number (Street or block #/nearby Months Height for Age
(Surname, First Name, M.I.) Caregiver (Surname, First, M.I.) MM/DD/YY Length/Height MUAC Status
landmark) Status
Status
Column 1 Column 2 Column 3 Column 4 Column 5 Column 6 Column 7 Column 8 Column 9 Column 10

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