Weight (kg) Length/Height (cm) Weight for Length/Height (kg)

Severely Severely Severely

Underweight Normal Overweight Stunted Normal Tall Wasted Normal Overweight Obese
Underweight Stunted Wasted

< -3SD -3 SD < -2 SD -2 SD +2 SD > +2 SD < -3SD -3 SD < -2 SD -2 SD +2 SD > +2 SD < -3SD -3SD < -2SD -2SD +2SD > +2SD +3SD > +3SD
 Date of
Date of Birth Weighing/Mea Age in Weight Height Weight for Height for
No Name Sex
(MM/DD/YYYY) suring Months (kg) (cm) Age Status Age Status
(MM/DD/YYYY)

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
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22
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27

Nem of Day Care Center:

Name of Day Care Worker: