HANDOUT 10.3. Sample NACS Client Card Facility name ______________________________ Facility code ________________________ ☐ ☐ Client name _________________________ Client number ________ Sex (tick one ): M F ☐ ☐ ☐ ☐ Age (years) ____ Age group (tick one ): 0–< 6 months 6–59 months 5–14 years 15–17 ☐ years ≥ 18 years Transferred from __________ Date ___⁄___⁄__ Transferred to ___________ Date ___⁄___⁄__ Referred to ________________________ Date ___⁄___⁄__ Tick if yes Quantity of Nutritional specialized status food product Exit reason (tick one ) prescribed (tick one ) months 6 edema? to (cm) nutrition? BMI-for-age up or on failure or pitting complications? (kg) RUSF follow-up (cm) BMI, Outpatient Inpatient to or Visit Weight WHZ, MUAC Medical MAM no. Date Overweight/obese Normal Graduated Died Bilateral Pregnant postpartum? Counseled RUTF SAM SAM F-75 F-100 FBF Transferred Treatment Length/height Lost 1 2 3 4 5 6 7 6 7 8 9 10
HANDOUT 10.3. Sample NACS Client Card Facility name ______________________________ Facility code ________________________ Client name _________________________ Client number ________ Sex (tick one ): ☐ M ☐ F Age (years) ____ Age group (tick one ): ☐ 0–< 6 months ☐ 6–59 months ☐ 5–14 years ☐ 15–17 years ☐ ≥ 18 years Transferred from __________ Date ___⁄___⁄__ Transferred to ___________ Date ___⁄___⁄__ Referred to ________________________ Date ___⁄___⁄__ Visit no. Date Length/height (cm) Weight (kg) MUAC (cm) WHZ, BMI, or BMI-for-age Tick if yes Nutritional status (tick one ) Quantity of specialized food product prescribed Exit reason (tick one ) Medical complications? Bilateral pitting edema? Pregnant or up to 6 months postpartum? Counseled on nutrition? SAM Inpatient SAM Outpatient MAM Normal Overweight/obese F-75 F-100 RUTF FBF or RUSF Graduated Lost to follow-up Died Transferred Treatment failure 1 2 3 4 5 6 7 6 7 8 9 10
Generic-NACS-Participant-Handouts-Dec2015.docx