ANNEX 4

SNS-MSP / HCU- 056/2009

TEENAGE ATTENTION

Surnames Paternal Maternal Names Medical history number

ESTABLISHMENT

BIRTHDATE

ADDRESS Code 1111111

PROVINCE, CANTON, PARISH TEL address □
day month year

PLACE OF BIRTH Cell phone: message □

MAIN QUERY years months COMPANION MARITAL STATUS single □ stable union □
only mother □ father both □
separated □
couple friend □ relative others □
DATE AGE
This
colo
r
mea
ns 1. REASON FOR CONSULTATION REASON FOR CONSULTATION (according
ALE
RT (according to adolescent): to companion):
1 1

2 2

3 3
2. CURRENT ILLNESS

OTHERS
3. PERSONAL BACKGROUND INFECTIOUS
USE OF ABUSE JUDICIAL
COMPLETE CHRONIC ACCIDENTS SURGERY MEDICINES OR PSYCHOLOGICAL
CONTAGIOUS SUBSTANCES
PERINATAL NORMAL VACCINES no yes DISEASES no I don't INTOXICATION no HOSPITALIZATION no DISORDERS no I
Normal GROWTH no DISEASES no I don't
PERINATALS DEVELOPMENT but
yes no yes no □□□ know if □□□ I don't know if □ □□ I don't know if □ □□ no I don't know if don't know if □ □□ no I don't know if □ no I don't know if □
normal no yes no yes no know if □ □□ □□
□□□
□□□ □□□ □ □□ □□ □□

Observations

4. FAMILY HISTORY OTHERS

CARDIOVASC. ALLERGY INFECTIONS PSYCHOLOGICAL INTRAFAMILY JUDICIAL

DIABETES no I don't OBESITY no I don't (HBP, heart disease, etc.) TEENAGE MOTHER no Yes
DISORDERS no I don't ALCOHOL DRUGS no VIOLENCE no I don't
know if □□□ know if □□□ □□
no I don't know if □□□ no I don't know if □□□ no I don't know if □□□ know if □□□ I don't know if □□□ know if □□□ no I don't know if □□□ no I don't know if □□□

Observations

5. FAMILY LEVEL OF INSTRUCTION FAMILY DIAGRAM 6. LIVING but

LIVE WITH
At In the
No home room ELECTRIC POWER

□□□ □ □
Parent or surrogate Mother or surrogate

□
mother illiterate

father
□
□
prim. incomp.

□
In the home out of home

□ □
primary
WATER

□ □
stepmother secondary/
technical
EXCRETES
university/
stepfather tertiary

siblings
JOB
NUMBER OF ROOMS
Parent or surrogate Mother or surrogate
couple
□ none
son
□ not stable □
Observations
others stable
Adapted from the CLAP-PAHO/WHO HdA

LIVES
No Ye
ah OCCUPATION Family Apgar
in institut.
□ 0 - 3 Severely Dysfunctional Families
□ 4 - 6 Moderately Dysfunctional Families
on the street
• 7 -10 Functional Families
FAMILY PERCEPTION OF THE TEENAGER
only

Good Fair Bad No relationship

□□ □□
SHARE THE BED
Observations

SNS-MSP/HCU Form # 056 / Attention adolescents

2009
 DEGREE COURSE YEARS REPEATED YEARS no yes no Yeah

3
7. EDUCATION STUDIES DESERTION EDUCATION no n yes n NO FORMAL
APPROVED EXCLUSION □□
LEVEL
PROBLEMS AT SCHOOL
Did not attend school □
Which?
Causes
No Yeah
Yeah No Prim.□ Causes
□ □
□ □ Sec. □ Univ. □

Observations

R AZ TYPE OF JOB
8. WORK ACTIVITY AGE STARTING JOB
WORK WORK HOURS LEGALIZED UNHEALTHY
WORK ON economic
□ Work □ Search for the 1st time WORK WORK
morning □ all day □ afternoon □ night □ autonomy I like
years
No and not looking □ Unemployed yes no n/a no yes n/a
weekend □ n/c□ another □n / c
□ □□ □ □□
Hours per week
This color means ALERT

Observations

9. SOCIAL LIFE ACCEPTANCE but ACTIVITY

Hours per OTHERS yes □ no □ Which ones
GROUP
accepted SPORT week ACTIVITIES
BOYFRIEND □ □ yes no
ignored Yeah No

□ □
FRIENDS □ □
rejected don't hours per day
TV
know

Observations

no
10. HABITS AGE STARTING
ALCOHOL
AGE BEGINNING OTHER TOXIC no Yeah DRIVE • VEHICLE yes □
PROPER FOOD MEALS PER DAY WITH TOBACCO ALCOHOL
MEALS PER DAY □ □
FAMILY
DREAM Frequency and type Which?
Yeah No TOBACCO cigarettes years years
NORMAL hours
□ □ □
but
□
□□_ equivalent to liters of beer
per week

Observations
per day
11. GYNECO- DATE OF LAST MENSTRUATION
CYCLES DYSMENORRHEA FLOW DISEASES OF no n
SEXUAL TRANSMISSION no PREGNANCY □
UROLOGICAL
MENAARCH/SPERMARCH □ Does not know Not REGULAR PATHOLOGICAL
corresponding SECRETION yes □
years months
day month year PENIS CHILDREN
Which?
yes no n/a yes no n/a but
ABORTIONS
□ □□ □ □□ □□ —

Observations

12. SEXUALITY RELATIONSHIPS not COUPLE AGE BEGINNING PROBLEMS IN REL CONTRACEPTION □ always □ CONDOM
SEXUAL □ hetero homo REL SEX. volunteers SEXUAL ABUSE Yeah
SEX.
single couple several □ always never
but no yes n/a never □ sometimes □ n/a □□
NEEDS both □ □ □ but
couples n/a □ sometimes □ n/a
INFORMATION uu □□ □ □□

years

Observations
13. PSYCHOEMOTIONAL SITUATION
BODY IMAGE SELF-PERCEPTION
□ sad □ nervous □ happy □ shy
□ as □ creates concern □ prevents relationships with
ADULT REFERENT LIFE PROYECT
others □ other □ father □ another family □ confusing
□ mother □ outside the home □ none □ clear □ absent
Observations

14. EXAM WEIGHT (K g) Centile weight/age

PHYSICAL
SKIN AND FANERALS VISUAL ACUITY HEARING ACUITY NECK AND THIRDS
SD/BMI MOUTH AND
GENERAL APPEARANCE normal abnormal normal abnormal TEETH normal abnormal □ □
normal abnormal □ □ normal abnormal □ □
SIZE (mm) DE size/age □□ □□
normal abnormal □ □

BLOOD PRESSURE
CARDIO- 57 ABDOMEN COLUMN EXTREMITIES NEUROLOGICAL
CHEST AND BREASTS PULMONARY GENITO-URUNARY normal

FREQUENCY TO CARDIAC TANNER

normal abnormal □ □ normal abnormal abnormal □ □ normal abnormal normal abnormal normal abnormal
normal abnormal
□□ □□ □□ □□
□□ 11 pub hair breasts. genitals
beats/min.
□□□

Observations

15. DIAGNOSES - CIE

16. INDICATIONS AND INTERCONSULTATIONS

IIIII II IIIIIIT

Responsible
 ANNEX 5
EVOLUTION FORM
TEEN
AGE
EVOL
UTIO
N
SHEE
T
 Surnames Paternal Names No. Clinic history

na
er
M
at

l
SN
S- TEENAGER WOMAN
MS
P/ Weight/Age, 10 to 19 years. Percentiles ANN
HC
U EX 6
For
m. SNS-
05
6A MSP /
wo
me HCU-
n/
20 056
09 A/200
Att
ent
9•
ion CAR
ad
ole E
sc
ent FOR
s
ADO
LESC
ENTS

1. According to the date of birth, establish the age in years and months.
2. Measure the teenager and write down the result in centimeters.
Weigh the adolescent and record the result in Kg. and hundreds of grams. During the physical examination, determine the
stage of pubertal development according to the graphs on the back of this page.
3. Locate the adolescent's age at the time of the consultation, on the lower horizontal line of the graph.
4. Mark with a point the place where the current age intersects with the weight in Kg. and hundreds of grams with the size in cm.
5. Analyze the individual situation, observing the adolescent's progression in the curves and the different
interrelationships of the evaluated parameters.
NCHS/2000
 Body Mass Index / Age, 10 to 19 years. Standard Deviations Growth Speed (Height), 10 to 18 years. Percentiles

Age, Months, Years

WHO 2007
INSTRUCTIVE
After obtaining the weight in Kg. and height in meter and first decimal, the weight is divided by the height squared: P (Kg.)/ T
(m 2 ). The value obtained is graphed with a point at the site where the value obtained intersects with the current age.

EVALUATION OF SEXUAL MATURATION: TANNER STAGES

Adult-type hair in the shape of a triangle with

an upper base, extending to the upper inner Adult mammary gland with return of areola to the

thigh region glandular surface, forming the nipple

IV
Adult hair in quality and quantity but with Elevation of the areola and mamelon forming a
less widespread topography prominence in relation to the rest of the gland

The darker, thicker hair extends over the mons Visible breast growth, with palpable glandular tissue.
pubis and slightly over the pubis. Pigmentation of the mamelon and areola III

Growth of long, pigmented or slightly curly Appearance of the primary breast bud Fund. Faustino Orbegozo Eizaguirre
hair on the lips or mons pubis and areola elongation

INSTRUCTIVE
The height is taken at two different times, the interval between the two measurements should not be less
than 3 nor more than 18 months; The difference is obtained in centimeters, which is divided by the
Childish appearance
number of months elapsed between them, and the value obtained is then multiplied by twelve. The
result obtained is graphed halfway between the two measurements.
Modified from E. If I read
 No. Clinic history

es
m
Na
Surnames Paternal Maternal

SN
S- TEENAGE MAN
M
SP Weight/Age, 10 to 19 years. Percentiles Size/Age, 10 to 19 years. Standard Deviations
/

SNS-MSP / HCU- 056 B/2009 • ATTENTION TO ADOLESCENTS

H
C
U
Fo
rm
.
05
6B
me
n/
20
09

Att
en
tio
n
ad
ol
es

ANNEX 7
ce
nt
s

no 1 ' ' ' 1 ' ' ' 1 ' ' ' 1 ' ' ' 1 ' ' ' 1 ' ' ' 1 ' ' ' 1 ' ' ' 1 ' ' ' 1
age/ 369 369 369 369 369 369 369 369 369
years 10 11 12 13 14 15 16 17 18 19

Age, Years, Months

WHO 2007
INSTRUCTIVE
1. According to the date of birth, establish the age in years and months.
2. Measure the teenager and write down the result in centimeters.
Weigh the adolescent and record the result in Kg. and hundreds of grams. During the physical examination, determine the
stage of pubertal development according to the graphs on the back of this page.
3. Locate the adolescent's age at the time of the consultation, on the lower horizontal line of the graph.
4. Mark with a point the place where the current age intersects with the weight in Kg. and hundreds of grams with the size in cm.
5. Analyze the individual situation, observing the adolescent's progression in the curves and the different
interrelationships of the evaluated parameters.
NCHS/2000
 s
ion
viat
De
ard
nd
Sta
.
ars
ye
19
to
10
e,
Ag
/
ex
Ind
ss
Ma
dy
Bo
Growth Speed (Height), 0 to 18 years. Percentiles

HEALTH MEAT
I must go to a health center or subcenter OF ADOLESCENCE
to request my Adolescent vaccination card WOMEN
cents, Youth and Adults of the Expanded Program
of PAL Immunizations
5

Surnames Names
EV
AL
UA Vaccines for adolescents from 10 to 19 years
TI old:
O A
N NAME OF

N
BIOLOGICAL AGE APPLICATION DATE BATCH
VACCINATOR
OF CHICKENPOX First dose 1 or contact
SE
N
(10 years old)

XU First dose 1st contact

AL
M H6 HEPATITIS Second dose (one
e month after the first)
E
AT
U Third dose (6 months
after the second)
X
RA
TI
First dose 1st contact 8
O Second dose (one

CAR
DT month after the first)
WHO 2007
DIPHTHERIA
N: INSTRUCTIVE TETANUS

TA
D OF
From 15 to 45 Third dose (one year
After obtaining the weight in Kg. and height in meter and first decimal, the weight is divided by the height squared: P years in women after the second)
N and from 15 to Fourth dose (one
(Kg.)/ T (m 2 ). The value obtained is graphed with a point at the site where the value obtained intersects with the current
59 years in men year after the third)

THE

e
at
hd
rt
Bi
NE Day
R age. Reinforcement every
Year Mont
h
EVALUATION OF SEXUAL MATURATION: TANNER STAGES 10 years
ST
A
SR MEASLES
RUBELLA Single dose
AND
G
ES V = Volume
Hair covers the scrotum and
extends to the inner thighs Testicle: V: 20-25 ml. DM: 5 cm.
HEALTH FACILITY ANTHROPOMET
RY
THE
ADO
and linea alba Penis: definitive size
DM = Largest diameter

I have the right to quality and warmth care, in the PROVINCE Weight ...... ....... gr.

that I am the protagonist of my development process.

Scrotum: More marked growth and CANTON Size ........... ..... gr. LES
Thicker, curly hair invades the
pubic area, without reaching the
pigmentation until the adult stage Testicle:
V:12-15 ml. DM: 4.1 - 4.5 cm. Penis: Growth
Each consultation
HEALTH AREA
CEN
adult stage in length and diameter. Developmentis confidential, everything said in consultation
of the
glans
is
PARISH
T
CLINICAL HISTORY No

The hair is darker, thicker

secret between me and whoever cares for me... confidentiality
and curly and extends over
the pubis
Scrotum: Growth and dark pigmentation Testicle: V:
8-10 ml. DM: 3.3-4 cm.
Penis: Growth in length
It allows me to speak without fear. IIIIIII
Integral Some hairs located at the base Scrotum: Growth with thin, lax, elastic, pink,
Fund. Faustino Orbegozo Eizaguirre

Health of the penis, long, lightly

It is my right and
pigmented, straight or slightly
transparent skin.
Testicle: V: 4 - 6 ml. DM: 2.5 to 3.2 cm. Penis
curly unchanged. INSTRUCTIVE
my Ministry of Public Health The height is taken at two different times, the interval between the two measurements
should not be less than 3 nor more than 18 months; The difference is obtained in
respo Testicles Av. Republic of El Salvador N°.95O and
Absent pubic V: < 3 mi.
Sweden centimeters, which is divided by the number of months elapsed between them, and the
hair DM: <2.5 cm.
value obtained is then multiplied by twelve. The result obtained is graphed halfway
Tel: 3 814400 www.msp.gov.ee
between the two measurements.
Modified from E. If I read
NATIONAL SYSTEM OF HEALTH
 HEALTH CARD
Tips to stay healthy
I must go to a health center or subcenter OF ADOLESCENCE
Start the day with breakfast to requesttomy have energyvaccination card
Adolescent Consume raw vegetable oils of soy, corn, sunflower,
Eat a wide varietycents, of different foods throughout the day MAN
Youth and Adults of the Expanded Program olive and canola with meals.
Eat five times a day (breakfast, of PALsnack, lunch, snack
Immunizations Prefer to eat skinless fish and poultry to protect your
and snack) heart
Eat at least three fruits a day, especially seasonal Surnames
Eat less salt and salty foods Names
EV
AL fruits Drink safe water
UA
TI There should always Vaccines be three servingsfrom
for adolescents of vegetables
10 to 19 years Practice sports that you like, with friends or family or
O in your daily diet. old: do physical activity for at least 30 minutes a day
N
OF Daily consumption of dairy products
BIOLOGICAL promotes
AGE APPLICATION DATE healthy
BATCH NAME OF Reduce consumption of fats and sugary drinks you
VACCINATOR
SE growth and development
CHICKENPOX First dose 1 contact or give
XU (10 years old)

AL First dose 1st contact

M
AT Body Mass Index / Age, 10 to 19 years. PercentilesHB8 (11
6-10 SERVINGS
HEPATITIS Second dose (one
years) month after the first) Size/Age, 10 to 19 years. Standard Deviations
U
Third dose (6 months
RA after the second)

TI First dose 1st contact

O
Second dose (one
N: DT
DIPHTHERIA month after the first)
TA TETANUS
Third dose (one year
N From 15 to 45
years in women after the second)
and from 15 to
NE 59 years in men
Fourth dose (one
year after the third)
Birthdate
R Year Month Day
Reinforcement every
ST 10 years

A SR MEASLES
RUBELLA Single dose
G
ES ANTHROPOMETRY HEALTH ESTABLISHMENT

PROVINCE Weight .................................................................... gr.

I have the right to quality and warmth care, in the
CANTON Size ........................................................................... gr.
that I am the protagonist of my development process. PARISH HEALTH AREA __________ CLINICAL HISTORY No

Each consultation is confidential, everything said in

Consultation is a secret between me and the person
who assists me...
Confidentiality allows me to speak without fear.

Integral UGUD0G@
Health
It is my right and Ministry of Public Health
my

07
20
bility.

O/

W
07
20
O
H
W

H
Av. Republic of El Salvador N°.95O and w
Sweden
Tel: 3 814400 www.msp.gov.ee
NATIONAL SYSTEM OF HEALTH
 Tips to stay healthy
Start the day with breakfast to have energy
Eat a wide variety of different foods throughout the
day
Eat five times a day (breakfast, snack, lunch, snack
and snack)
Eat at least three fruits a day, especially seasonal
fruits
There should always be three servings of vegetables
in your daily diet.
Daily consumption of dairy products promotes healthy
growth and development
Size/Age, 10 to 19 years. Standard Deviations Body Mass Index / Age, 10 to 19 years. Percentiles
Consume raw vegetable oils of soy, corn, sunflower,
olive and canola with meals.
Prefer to eat skinless fish and poultry to protect your
heart
Eat less salt and salty foods
Drink safe water
Practice sports that you like, with friends or family or
do physical activity for at least 30 minutes a day
Reduce consumption of fats and sugary drinks you
give