Location:
GROWTH, NUTRITION AND DEVELOPMENT MONITORING
Visit
Date
Age
(Wks/Mths)
Weight
(Kgs)
Height
(Cms)
Infant
Feeding
Medication Given
If HIV Exposed
TB
Assessment
Outcome
Date of Next
Appointment
NVP
(mls)
CTX
(mls/mg)
M/vit
(a) (b) (c) (d) (e) (f) (g) (h) (i) (j)
MILESTONES
Development Milestones by Age Achieving Milestones?








LABORATORY INFORMATION
Type of Test Date of Sample
Collection
Test Contextual
Status
Results DBS Sample Code Date Results Collected
DNA PCR
First Antibody Test
Final Antibody Test
Early Eye Examination and Deworming
EYE CARE ASSESSMENT
Tetracycline
Eye Ointment
(TEO) Given?
PUPIL
SIGHT
SQUINT
(Crossed Eyes)
DEWORMING

Give once every six months to all children one year and
above: If Mebendazole 500mg or Albendazole 200mg
for children 1 to 2 years and 400mg for children 2 years
and above

Date of Next Visit
Age Drug Dosage/Units
Clinician's Notes