Nutrition Assessment Counselling & Support (N/A) Prescription Form

The form requires the prescriber to provide information about the patient, including the name of the patient and the name of the facility. The prescriber must also indicate the type of malnutrition (moderate or severe) and select the appropriate nutritional product to be prescribed. For moderate malnutrition, the prescriber can select from three options: RUTF (Ready-to-Use Therapeutic Food), HEPS (High Energy Protein Supplement), or Chlorine (for water treatment). For severe malnutrition, the prescriber can also select from these three options. The prescriber must tick the appropriate box to indicate the prescribed product. The form also includes a section for the prescriber to indicate the eligibility criteria for the prescribed product. The options include BMI (Body Mass Index), MUAC (Mid-Upper Arm Circumference), Weight-for-Height percentage, Z score, oedema, and presence of an oedema in a child aged 6-24 months. The prescriber must also sign and date the form to indicate their approval of the prescription. Additionally, the form requires the name and signature of the dispenser, who is responsible for collecting the prescribed amount of the prescribed product. The dispenser must also sign and date the form to indicate that the product has been collected. The form includes a section for the prescriber to indicate the amount of the prescribed product that has been collected. This section is used to track the distribution of the product and ensure that the correct amount is provided to the patient.