FORM BREAST FEEDING CLINICAL
CHSUNO Child survey number CHSUNO            
 CHSNO (Child serial Number, if given, if not, type 99999)  CHSNO          
Name of the Child          
BFC_1 Date (according to English calendar) BFC_1            
BFC_2 Physician code BFC_2    
Evaluation  of Cough / Difficult Breathing 
BFC_3 Difficult breathing and cough (1=yes, 2= no) BFC_3  
BFC_4 Duration of cough and difficult breathing (in days) BFC_4    
BFC_5 Respiratory Rate 1 BFC_5    
BFC_6 Respiratory Rate 2 BFC_6    
BFC_7 Condition of child (3=awake & quiet, 4=Breast feeding, 5=asleep) BFC_7  
BFC_8 Presence of lower chest indrawing (1=Yes, 2=No) BFC_8  
BFC_9 Presence of wheezing  BFC_9  
BFC_10 Presence of crepitations BFC_10  
BFC_11 Presence of murmur on auscultation of the precordium                                                                                       BFC_11  
BFC_12 Pneumonia (2=No, 3=Pneumonia,  BFC_12  
4=Severe pneumonia, 5=Very severe pneumonia)
Evaluation of Fever  (Code : 1=Yes, 2=No, 9=Not applicable)
BFC_13 Is there a history (complaint) of fever ? BFC_13  
BFC_14 Duration of fever (in days) BFC_14    
BFC_15 Temperature (oF) BFC_15        
BFC_16 Presence of ear discharge BFC_16  
Evaluation of Malnutrition & Anemia (Code : 1=Yes, 2=No, 9=Not applicable)
BFC_17 Presence of palmar pallor (2=None, 3=Some, 4=Severe) BFC_17  
BFC_18 Presence of visible severe wasting BFC_18  
BFC_19 Mid upper arm circumference (in mm) BFC_19      
     
BFC_20 Weight (in kg) BFC_20      
BFC_21 Height / Length (in cm) BFC_21        
BFC_22 History of any other problem in the child ? D_22  
BFC_22txt If yes, specify
BFC_23 Does the child have any other significant positive findings by clinical examination ? D_23  
BFC_23txt If yes, specify              
Supervisor ___________   Data Entry 1 ___________  Data Entry 2 ___________