| QNo. | Question and Instructions | Response | Codes | |
| 1 | Pallor | Yes No | 1 2 | |
| 2 | Jaundice | Yes No | 1 2 | |
| 3 | Pulse rate | Normal Bradycardia Tachycardia | 1 2 3 | |
| 4 | Respiratory rate | Normal Abnormal | 1 2 | |
| 5 | oxygen saturation | >90% in room air <90% in room air | 1 2 | |
| 6 | Weight |
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| 7 | Height |
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| 8 | Weight for height | No malnutrition Mild malnutrition Moderate malnutrition Severe malnutrition | 0 1 2 3 | |
| 9 | Height for Age | No stunting Mild stunting Moderate stunting Severe stunting | 1 2 3 4 | |
| 10 | BMI for Age | No malnutrition Mild malnutrition Moderate malnutrition Severe malnutrition | 1 2 3 4 | |
| 11 | Tanner stage | stage 1 stage 2 stage 3 stage 4 stage 5 | 1 2 3 4 5 | |
| 12 | Malocclusion | Yes No | 1 2 | |
| 13 | Bossing of the skull | Yes No | 1 2 | |
| 14 | Leg ulcers | Yes No | 1 2 | |
| 15 | Hepatomegaly | Yes No Size of the liver | 1 2
| |
| 16 | Splenomegaly | Yes No Size of the spleen | 1 2
| |
| 17 | Abnormal CNS findings | Yes No If yes (specify) | 1 2
| |
| 18 | Abnormal auscultations findings | Yes No | 1 2 | |
| 19 | Any medical diagnosis found on evaluation today (mention) | Yes No If yes (specify) | 1 2
| |