Professional Documents
Culture Documents
1. Is your child breast fed? ☐ Yes ☐No or formula fed? ☐ Yes ☐No or both? ☐ Yes ☐No
What?
When ?
How much?
5. At what time does your child eat food during the day? (Other than formula or milk)
6. Please indicate which, if any, of these foods your child eats and how often
10. Does your child take vitamins or iron drops? ☐ Yes ☐No
How often
If yes, why?
12. Is there delay in physicians ordering the initiation of nutriment supplements? ☐ Yes ☐No
13. How long are you waiting for physician to assess the child? ☐ Yes ☐ No
14. Is nutrition therapy routinely discussed on child follows up? ☐ Yes ☐ No
15. How long are waiting for the dietitian to assess the child? ☐ Yes ☐ No
16. Is Dietitian routinely present on weekday during child follows up? ☐ Yes ☐ No
17. Is there enough time dedicated to education and training on how to optimally feed your child? ☐
Yes ☐No
18. Is Nutritional supplement always available in the hospital? ☐ Yes ☐ No
19. Does your child already suffered or is suffering from:
Tuberculosis ☐ gastro-enteritis ☐ pneumonia ☐ Anemia ☐ Oral thrust ☐ Others☐
Specify:
20. Is blood collected every six months to monitor HIV disease? ☐ Yes ☐ No
21. Estimated distance from home to the Health Centre?
< 10 Km ☐ 10 à 25 Km ☐ 25 à 50 Km ☐ > 50 Km☐
22. How often do you forget to give your child the medications (per week?)
1 Time ☐ 2 Times ☐ ≥ 3 Times ☐
23. How often did you miss your child’s appointments this year? 1 Time ☐ 2 Times ☐ ≥ 3 Times ☐
24. Is there any traditional medications administered to your child? ☐ Yes ☐ No