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Anemia Quest

1. The document is an anemia questionnaire for children ages 3-5 used by Aldine Independent School District to screen for iron deficiency anemia. 2. Iron deficiency anemia is a low blood level of iron, usually related to low dietary iron intake or increased iron needs during growth periods. 3. The questionnaire asks parents questions about the child's diet, medical history, and symptoms to determine if further blood testing is needed to diagnose anemia.

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776 views1 page

Anemia Quest

1. The document is an anemia questionnaire for children ages 3-5 used by Aldine Independent School District to screen for iron deficiency anemia. 2. Iron deficiency anemia is a low blood level of iron, usually related to low dietary iron intake or increased iron needs during growth periods. 3. The questionnaire asks parents questions about the child's diet, medical history, and symptoms to determine if further blood testing is needed to diagnose anemia.

Uploaded by

ayaz
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

Aldine Independent School District Anemia Questionnaire for ages 3-5 years old

Child’s Name: _______________________________________________ Date Completed:____________________


(Last) (First)
Parent/Guardian: ____________________________________ Staff Name: _________________________________

Translation Provided: ____N/A ____Spanish/English Translator’s Name: _________________________________

DEFICIENCY ANEMIA definition: Iron Deficiency Anemia- is low blood level of iron. It is usually related to a low
intake of dietary iron and/or increased iron requirements during rapid growth periods. This questionnaire is only a
screening tool to help identify if your child is at risk for being anemic. A blood test is the only way to diagnose anemia.
Instructions: Staff review questionnaire with parent/guardian and place a  in the appropriate box. DO NOT
COMPLETE THE POINTS BOX; Health staff will complete this box.

Question: Yes No If YES to both #1 & 2


1. Is your child currently enrolled in the Women, Infant, and STOP HERE!
Children (WIC) program? If NO to one or both
2. Is your child currently being treated or followed by WIC or continue below
a physician for the diagnoses of being anemic (low iron)?
If yes to both #1 & 2- No further testing is needed at this time and the child will be documented as Not High
Risk. Documentation from WIC and/or physician will be requested for your child’s file.

IF NO to one or both questions above, please continue below:


Question: Yes No Total Points
3. Was your child enrolled in the WIC program at 24 months of age? 1 0
4. Does your child currently take prescription iron supplements or a daily multi- 5 0
vitamin that contains iron?
5. Did your child start cow’s milk prior to 12 months of age? 0 1

6. Does your child currently or often seem to be tired or have decreased 0 1


activity?
7. Does your child currently or often seem to be irritable? 0 1

8. Does your child currently or often seem to have a loss of appetite? 0 1


9. Does your child currently or often appear to be pale in color? 0 1

10. Does your child eat meat, fish poultry, beans, eggs, or peanut butter at least 1 0
1-2 times per day?
11. Does your child currently or often seem to have a loss of interest their 0 1
surroundings?
12. Does your child have frequent nosebleeds? 0 1

13. Does your child’s gums bleed easily? 0 1

14. Does your child tend to bruise easily? 0 1


15. Is your child prone to frequent colds or infections? 0 1

16. Does your child have any of the following medical conditions? Cyanotic 0 1
Congenital Heart Disease, Iron loss from gastrointestinal tract or pulmonary
bleeding, urinary iron loss?
Total points:

Determination: _____Not High-Risk- No further Determination: ____High Risk- Hematocrit and/or


testing indicated at this time. Hemaglobin test indicated.
Points of 7 or > Points of 6 or <

Date of Determination: ___________________ Determined by: ________________________________________

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