Progress Reports
Case #
B-
05
-
*
Organization Name
*
Name of person completing status report questionnaire
*
Has the phone number changed?
If so, please give new phone number
Has e-mail address changed?
Email
Total number of caregivers in organization.
*
Number of children by age: 0-1 years:
*
Number of children by age: 2-3 years:
*
Number of children by age: 4-5 years:
*
Number of children by age: 6-12 years:
*
Number of children by age: 13-18 years:
*
Number of children living in Huts
*
Number of children living in Cottages
*
Number of children living in Dormitories
*
Number of children living in Other
*
Other, describe:
*
Number of children in Good Health
*
Number of children in Moderate Health
*
Number of children in Poor Health
*
Number of children in Critical Health
*
How many meals per day do the children receive?
Yes
2
3
4
5
*
Estimated number of calories each child receives each day.
*
What kinds of food is served
Number of children by disorder: AIDS:
*
Number of children by disorder: Malaria:
*
Number of children by disorder: Malnutrition:
*
Number of children by disorder: Sickle Cell:
*
Number of children by disorder: Skin Conditions:
*
Number of children by disorder: Digestive Problems:
*
Number of children by disorder: Learning Disabilities:
*
Number of children by disorder: Respiratory Illness:
*
Number of children by disorder: Leprosy:
*
Number of children by disorder: Tuberculosis:
*
Number of children by disorder: Fevers:
*
Number of children by disorder: Stunted Growth:
*
Number of children by disorder: Behavior Problems:
*
Number of children by disorder: Problems Gaining Weight:
*
Number of children by disorder: Other:
*
Other, describe:
*
Do medical teams visit the organization?
No
Yes *
How often per month?
Yes
2
3
4
5
*
Is blood work taken from any of the children?
No
Yes *
Do you keep medical records?
No
Yes *
Do you keep growth records (height and weight)?
No
Yes *
Approximately how many GlycoBear vitamins does each child receive each day?
Yes
2
3
4
5
6 *
How much Ambrotose powder is given to the seriously ill children on a daily basis?
*
Number of children who have improved: AIDS:
*
Number of children who have improved: Malaria:
*
Number of children who have improved: Malnutrition:
*
Number of children who have improved: Sickle Cell:
*
Number of children who have improved: Skin Conditions:
*
Number of children who have improved: Digestive Problems:
*
Number of children who have improved: Learning Disabilities:
*
Number of children who have improved: Respiratory Illness:
*
Number of children who have improved: Leprosy:
*
Number of children who have improved: Tuberculosis:
*
Number of children who have improved: Fevers:
*
Number of children who have improved: Stunted Growth:
*
Number of children who have improved: Behavior Problems:
*
Number of children who have improved: Problems Gaining Weight:
*
Number of children who have improved: Other:
*
Other, describe:
*
Products currently remaining in inventory of Bottles of GlycoBears
*
Products currently remaining in inventory of Tubs of Ambrotose Plus
*
Next date someone is know to be traveling to visit this organization and can deliver products?
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Please add any comments or requests you like.