SIS-SS-18-P

HEALTH SECRETARY NUTRITION STATUS CONTROL CARD OF THE GIRL AND THE BOY DATE OF ADMISSION _______/_____/__________

CLUES NAME OF THE UNIT LOCATION MUNICIPALITY JURISDICTION ENTITY

NAME OF SERVICE PROVIDER: _______________________________________________________________________ TYPE OF STAFF: GENERAL DOCTOR|__| SPECIALIST DOCTOR|__| NUTRIOLOGIST|__| NURSE|__| OTHER|__| SERVICE: ________________________________________________

IDENT I FICAC I N DATA PERSONALIZED CONTROL OF THE DETECTION OF ANEMIA IN CHILDREN UNDER 5 YEARS
l. s r- s: SPSS: OF AGE
PROCEEDINGS □ SPSS AFFILIATION 1 1 1 1 1 1 1 1 1 1 1 LLU AGE Program Date of
Detection years/month Date tion realization Result Referred Observations
PROSPERS ............... । । । । । । । । । । । । । । । । । DATE OF ADMISSION*__________/____/_______ s

BIRTHDATE* _____/_____/__________ ENTITY OF BIRTH TO GENDER: FEMALE MAN 1°

NAMES)* SURNAMES: FIRST* 2°
SECOND
CURP* 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1°
THE FAMILY OF YEAH
CLARA BELONGING TO AN INDIGENOUS PEOPLE 2°
0 NO □
AT BIRTH: WEEKS OF GESTATION g r. SIZE .
_________________ WEIGHT__________________ _________________cm 1°

NAME OF MOTHER*: 2°

HOME 1°

2°
LANDLINE 1111111111 CELL 1111111111 1°
PHONE
EMAIL: 2°

APPOINTMENT CONTROL
ON THE TRACK OF
NUTRITIONAL DIAGNOSIS* RECOVERY RECOVERED BREASTFEEDING FOOD AID < 5
WEIGHT SIZE AGE VISIT years
< 5 years 5 to 9 years < 5 years 5 to 9 years < 5 years 5 to 9 years EXCLUSIVE From 6 ORIENTATION
DATE grams centimeters years/month
s
REFERRED ADDRESS
LIARIA Children months to FOOD 3 OBSERVATIONS
Weight for Weight for Weight for under 6 under 3
Size for Age 2 BMI 1 BMI 1 BMI 1 months years Yes Yo
Size 1 Size 1 Size 1

ABBREVIATIONS OF NUTRITIONAL DIAGNOSIS

1. Weight for height (P/T) and Body Mass Index (BMI): OB .Obesity, SBP .Overweight, N .Normal, DL .Mild malnutrition (P/T), DM .Moderate malnutrition (P/T), DG .Severe malnutrition (P/T), BP .Under weight (BMI).
2. Size for Age: TA .High size, TN .Normal size, TB .Low size.

3. DIETARY GUIDANCE: 1. BREASTFEEDING from 0 to 6 months ; 2. SUPPLEMENTARY FOOD from 6 months to 1 year ; 3. INTEGRATION INTO THE FAMILY DIET at the first year of age ; 4. CORRECT FEEDING in children over one year old and up to 9 years of age.
OBVERSE SIS-2017
 SIS-SS-18-P

HEALTH SECRETARY q NUTRITION STATUS CONTROL CARD OF THE GIRL AND THE BOY
HEALTH SECRETARY

CLUES NAME OF THE UNIT LOCATION MUNICIPALITY JURISDICTION ENTITY

PROCEEDINGS _________________________________________________________ NAME___________________________________________________________________________________________________________________ BIRTHDATE _________________________________________________________/________/_________________

Name(s), paternal surname, maternal surname

APPOINTMENT CONTROL
ON THE TRACK OF
NUTRITIONAL DIAGNOSIS* RECOVERY RECOVERED BREASTFEEDING FOOD AID < 5
SIZE AGE HOME VISIT ORIENTATION years
DATE WEIGHT grams centimeters years/months < 5 years 5 to 9 years < 5 years 5 to 9 years < 5 years 5 to 9 years REFERRED EXCLUSIVE OBSERVATIONS
LIARIA Children From 6 3
Weight for Size for Age 2 Weight for Weight for months to FOOD
under 6
Size 1 BMI 1 Size 1 BMI 1 Size 1 BMI 1 under 3 years Yes Yo
months

ABBREVIATIONS OF NUTRITIONAL DIAGNOSIS

1. Weight for height (P/T) and Body Mass Index (BMI): OB .Obesity, SBP .Overweight, N .Normal, DL .Mild malnutrition (P/T), DM .Moderate malnutrition (P/T), DG .Severe malnutrition (P/T), BP .Under weight (BMI).
2. Size for Age: TA .High size, TN .Normal size, TB .Low size.

3. DIETARY GUIDANCE: 1. BREASTFEEDING from 0 to 6 months ; 2. SUPPLEMENTARY FOOD from 6 months to 1 year ; 3. INTEGRATION INTO THE FAMILY DIET at the first year of age ; 4. CORRECT FEEDING in children over one year old and up to 9 years of age.

LOW: REASON ___________________________________________________________ DATE ___/___/_________________________________ PHYSICIAN'S NAME AND SIGNATURE:

REASON FOR WITHDRAWAL: 1. Change of address ; 2. Refusal to treatment ; 3. Death ; 4 .Lost ; 8. Other .
REVERSE SIS-2017