FORM 3
CHILD NUTRINTIONAL STATUS & SELF-HELP FORM
Instructions to Parents/Guardians: The following information is required for
your child attending CDC for record purposes. Please complete this form
by providing information called for. For some of the items, the city/Rural/
Barangay Health Unit Officer (C/R/BHUO). Or Barangay Nutrition Scholar
(BNS) is required to provide the information. This form is the Child
Development Worker as part of the child’s portfolio.
BASIC INFORMATION
Child’s Name:
Last First Middle
Address:
Parent/ Guardian Name(s):
Relationship:
Phone Number(s): Work: Home:
Mobile Number:
NUTRITION INFORMATION:
Test/Measurement Results Date Taken
st nd st
1 2 1 2nd
Height
Weight
Nutritional Status
Name C/R/BHU Officer/BNS:
Phone No.:
Signature:
FORM 4
CHILD OBSERVATION RECORD
INSTRUCTIONS: This form will serve as the basis in determining te socio-
emotional development of the child, it must be accomplished fully by the
Child Development Worker and kept it in the child’s portfolio.
Child’s Name:
Sex: M F Age Guardian
Direction: Check (/) the behavior manifest by the child including the specific
comment.
BEHAVIOR COMMENT
st nd rd th With With Done
1 2 3 4
minimum Maximum Independently
assistance assistance
Ask for
help/assistance
Stands at the back
and observes other
playing
Choose an activity
independently
Initiates play with
another child or invites
another child to play
Responds to another
child’s invitation to
play
Joins a group that
already playing
Plays with toys or
something alone
Plays in a dramatic
play area
Plays in art area
Plays in another area
(indicate)
Plays block and other
manipulative materials
independently
Solves his problem or
find a solution
independently
Shows aggression or
loss of self-control
Accomplished by:
Signature over printed name of CDW Date
FEEDING EATING:
1. Does your child have any food allergies we need to be aware of?
2. What food do you usually give to your child?
3. What is your child eating habit? (i.e. bottles, finger foods, cereal, etc)
4. Is your child using a bottle? If so, how often will she/he take a
day?
5. What time does your child usually have? Breakfast: lunch:
dinner:
6. Is your child used to have a meal time snack? YES NO
7. What food is normally eaten by your child?
Vegetable Rice Cereals Noodles Fruit Juice
Chicken Soup Milk Meat Bread Fish Fruit
8. Does your child need any help in feeding himself/herself? YES
NO
NAPPING/ SLEEPING:
9. Does your child nap? YES NO
10. Does your child have a good sleep throughout the night? YES
NO
11. What time does your child get up in the morning? YES NO
12. Does your child have any special nap or bedtime routine? YES
NO
BATHING/ WASH-UP:
13. How do you bath/wash-up your child? How often?
14. Do you use baby soap? Any Soap? Baby shampoo?
15. Does your child have allergies in soap, etc.? Please specify
16. Do you put baby oil after/wash-up? Powder?
TOILETING:
17. Is your child toilet trained? YES NO At what age?
18. Is your child doing any toileting? How often?
19. Does your child have special word for urinating?
20. Is your Child using diaper? Cloth Disposable
21. How would you know if your child needs new diaper (she/he brings
diaper to you, cries, you have to check)?
22. How often do you change his/her diaper/baby clothes?
I ATTEST THAT ALL INFORMATION PROVIDED ON THIS FORM IS
TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE AND
BELIEF. I UNDERSTAND IT IS FOR CONFIDENTIAL USE IN MEETING
MY CHILD’S HEALTH NEEDS IN CDC.
Accomplished by:
Signature over printed name of parent/ guardian Date
Reviewed by:
Signature over printed name of CDW/CDT Date
FORM 5
PARENT INVOLVEMENT FORM
Instructions to the parents/guardian: Please check the box that correspond
to the statement that you think you can do. This form will keep by the Child
Development Worker for record purposes.
Parent/Guardian Name(s):
Relationship: Phone number(s): Work:
Home: Mobile Numbers:
Child’s Name:
Birth Date: Sex: M F
Address:
PROGRAM SUPPORT
Assist in preparing instructional materials (i.e. story/big books,
rhymes, etc.
Assist in the classroom routine/activity time
Assist in the outdoor play
Acts a storyteller
Read a book with children
Shares talent or knowledge (pls. specify
Plays a musical instrument/sing song with children
Lead a dance, song, etc.
Assist in the preparation of meals for feeding
Assist during snack time
Helps maintain the cleanliness of the classroom
Assist gardening at the school/with the children
Repairs/carpentry/paint
Shares discarded/ recyclable resources for work
FORM 2
PHYSICAL HEALTH INVENTORY FORM
Instructions to Parents/Guardians: The following information is required to a
child attending the CDC for record and referral purposes. Please complete
Part 1 of the Health Assessment Form. Part 2 must be completed by the
private licensed physician/ nurse. Municipal/Rural Health Unit Officer
(M/R/BHUO), or Barangay Nutrition Scholars (BNS). The center ensures
that each child has access to a thorough health assessment.
BASIC INFORMATION
Child’s Name:
Birth Date: Sex: M F
Address:
Parent/Guardian Name(s):
Relationship:
Phone Number(s): Work:
Mobile Number (s): ,
Accomplished by:
Signature over printed name of parents/guardian Date
Reviewed by:
Signature over printed name of CDW Date
FORM 1
REGISTRATION FORM
Instructions: This form is to be filled out by the parents/guardian of the child
upon enrollment to the Child Development Center. This will be kept by the
Child Development Worker in the portfolio of the child.
Name of Child: Sex:
Address: Birthday:
Guardian: Relationship:
Registered: Yes: No: Age:
Child’s first language: Second:
Guardian Information: E-mail Address:
Mother
Name: Occupation:
Address:
Contact Number: Home: Work:
Father
Name: Occupation:
Address:
Contact Number: Home: Work:
IN CASE OF EMERGENCY, please contact the following:
Name: Occupation:
Contact Number: Home: Work:
Accomplish by:
Signature over printed name of parents/guardian Date
Reviewed by:
Signature over printed name of CDW Date
ADMINISTRATIVE SUPPORT
Assist in Family support program
Assist in planning/organizing Family Day
Prepares food for an event
Assist to solicit/donate
Assist in making signage’s/graphic design
Assist in organizing/emergency planning
Assist in school program
Note any other ways you would like to get involved:
Accomplish by:
Signature over printed name of parents/guardian Date
Reviewed by:
Signature over printed name of CDW Date
PART 1- PHYSICAL HEALTH ASSESSMENT
To be completed by parent or guardian
Where do usually take your child for routine check-up?
Name of Hospital/Center:
Address:
When was the last time your child had a routine check-up? (mm/dd/yy) &
where? Date: Name of Hospital/Center:
ASSESSMENT OF CHILD’S HEALTH- To the best of your knowledge has
your child had any problem with the following? Check (/) YES or NO and
provide a comment for any YES answer:
YES NO Comments (required
for any YES answer)
Allergies (food, insect, Medicine, etc.)
Asthma
Bleeding
Bowels
Coughing
Diabetes
Ears or Deafness
Eyes or Vision
Other (Please indicate)
Does your child take medication (prescription or nonprescription) at any
time? YES, NO Name(s) of Medication(s):
Does your child receive special treatment (nebulize, etc.)
YES NO
I ATTEST THAT ALL INFORMATION PROVIDED ON THIS FORM IS
TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE AND
BELIEF, I UNDERSTAND IT IS FOR CONFIDENTIAL USE MEETING MY
CHILD’S HEALTH NEEDS IN CDC.
Signature of Parent/ Guardian Date
Republic of the Philippines
Province of Misamis Oriental
Municipality of Talisayan
Barangay Poblacion
EARLY CHILDHOOD CARE AND DEVELOPMENT
FEEDBACK FROM PARENTS ABOUT THEIR CHILD HOME
PERFORMANCE
Ako si ginikanan ni
Isip ginikanan among gitabangan ang mga kahuyang sa among anak diha
sa among panimalay sama sa;
Among gidasig usab ang among anak sa iyang talent og pinaagi sa among
pag amuma sa among anak, ug nakita/ na obsebahan sukad siya
nakasulod sa Child Development Center adunay kalamboan sa iyang
pagkabata.
Ngalan sa Ginikanan
PART II- CHILD HEALTH ASSESSMENT
