Pharmacies A j 0o NUTRITION STATUS CONTROL CARD FOR CHILDREN UNDER 5 YEARS OLD * DATE OF ADMISSION ___________ /__/______

Your generic expert •:e

DR RUIZ PEREZ JESUS JAVIER VILLA OF WELLS SAN LUIS POTOSI

DOCTOR LOCATION MUNICIPALITY
IDENTIFICATION DATA PERSONALIZED CONTROL OF THE DETECTION OF ANEMIA IN CHILDREN UNDER 5 YEARS OF
AGEDetection AGE Program Date of
years/month Date tion Result Referred
realization Observations
PROCEEDINGS 1 __________________1 SPSS: SPSS AFFILIATION 111111111 • s
ENTITY OF BIRTH • GENDER: FEMALE MAN
BIRTHDATE _____/_____/__________ 1°
NAMES) SURNAMES: PATERNAL 2°
MATERNAL
CURP 11 11 1 11 11 11 11 1 11 1 1°
THE FAMILY OF YES □ NO □
CLARA BELONGING TO AN INDIGENOUS PEOPLE 2°
AT BIRTH: WEEKS OF G SEASON___________________ WEIGHT______________________g. SIZE _______________________ .
1°
cm
MOTHER'S NAME: 2°
HOME 1°

PHONE: FIJ Or
111111111 CELL PHONE 111111111 2°
EMAIL RONIC: 1°
PHYSICIAN'S NAME AND SIGNATURE 2°

APPOINTMENT CONTROL
ON THE TRACK OF BREASTFEEDING
NUTRITIONAL DIAGNOSIS RECOVERY RECOVERED AID
WEIGHT HOME VISIT FOOD TARI <
DATE dd/mm/yyyy
grams
SIZE centimeters AGE years/months REFERRED LIARIA EXCLUSIVE DIETARY GUIDANCE & OBSERVATIONS
Children under 6 From 6 months 5 years
Weight for months to under 3 years
Weight for Size* Size for Age** Age*** Weight for Size* Weight for Size*

NUTRITIONAL DIAGNOSIS FOR EACH INDICATOR (ABBREVIATIONS)

* Weight for Size: OB. OBESITY; SP. OVERWEIGHT; RSP. RISK OF OVERWEIGHT; PN. NORMAL WEIGHT; RD. RISK OF MALNUTRITION; DM. MODERATE MALNUTRITION (WASTING); DG. SEVERE MALNUTRITION (SEVERE WASTE).
**Size for Age: TA. Tall size, TN. Normal size, RTB. Risk of short stature, TB. Short stature (wasting), TBS. Severe short stature (severe demedro).
*** Weight for Age (P/E): R3, R2, R1 (they are risks of malnutrition); N.Normal, ABP. Low weight alert, BP. Low Weight, BPS. Severe underweight.

& 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 of age and up to 5 years of age.
OBVERSE
 NUTRITION STATUS CONTROL CARD FOR CHILDREN UNDER 5 YEARS OLD
CLUES NAME OF THE UNIT LOCATION MUNICIPALITY AREA/REGION DELEGATION

PROCEEDINGS ___________________________ NAME____________________________________________________________________________________________________________________ BIRTHDATE ___________________________/_____/_________

Name(s), paternal surname, maternal surname

APPOINTMENT CONTROL
ON THE TRACK OF BREASTFEEDING
AGE NUTRITIONAL DIAGNOSIS RECOVERY RECOVERED AID
WEIGHT SIZE HOME VISIT EXCLUSIVE DIETARY
DATE grams centimeters years/months REFERRED LIARIA From 6 GUIDANCE & FOOD TARI < OBSERVATIONS
Children 5 years
Weight for Size for Weight for months to
under 6
Size* Age** Age*** Weight for Size* Weight for Size* under 3 years
months

NUTRITIONAL DIAGNOSIS FOR EACH INDICATOR (ABBREVIATIONS)

*Weight for Size: OB. OBESITY; SP. OVERWEIGHT; RSP. RISK OF OVERWEIGHT; PN. NORMAL WEIGHT; RD. RISK OF MALNUTRITION; DM. MODERATE MALNUTRITION (WASTING); DG. SEVERE MALNUTRITION (SEVERE WASTE).
**Size for Age: TA. Tall size, TN. Normal size, RTB. Risk of short stature, TB. Short stature (wasting), TBS. Severe short stature (severe demedro).
*** Weight for Age (P/E): R3, R2, R1 (they are risks of malnutrition); N.Normal, ABP. Low weight alert, BP. Low Weight, BPS. Severe underweight.

& 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 NUTRITION in those over one year of age and up to 5 years of age.

WITHDRAWAL: REASON AND DATE PHYSICIAN'S NAME AND SIGNATURE:

REVERSE SISPA-2017