se adjunta revisador por Elio Luis Mamani Gutierrez y Monica Mamani

RELACION

0
0

10

15

25

3
 3

15

20

96
RELACION
0
2 (<5) =
0 mas60 =
0 fumar >=

2 II >=
0 alcohol >=
0 droga >=

0 III >=

0 IV =
0 <5 =
0 mas60 =

0 <5
0 5a9
0 10 a 19
 0 20 a 29
0 30 a 59
0 60 o +
0 II <=

0 0 MASCULINO
<5
0 FEMENINO
0 MASCULINO
0 III >= 0 FEMENINO
5a9

0 MASCULINO
10 a 19
0 FEMENINO
0 MASCULINO
20 a 29
0 FEMENINO
0 MASCULINO
0 IV = 0 FEMENINO
30 a 59

0 MASCULINO
60 o +
0 FEMENINO
RELACION

0 fumar <=
0 alcohol <=
RELACION
0 droga <=
0

RELACION
9
7 si LEE=
9
7 si Escribe=
9

8 Nivel de Ins=
 8 Nivel de Ins=

432726
9
RELACION

9
0
0
0
0

0
0
0
0 0
0

0 MASCULINO
0 <5
0 FEMENINO

0 MASCULINO
0 5a9
0 FEMENINO
0 MASCULINO
0 10 a 19
0 FEMENINO
0 MASCULINO
0 20 a 29
0 FEMENINO

0 MASCULINO

0 30 a 59
 0 MASCULINO

0 30 a 59

0 FEMENINO

0 MASCULINO
0 60 o +
0 FEMENINO
 0
Numeros de Seguimientos de Carpetas Familiares 0 0 0 0 0 0 0 0 0 0 0 0 0
CARPETAS COMPLETAS,PARCIALES, BAJAS 0 0 0 0 0 0 0 0 0 0 0 0
I. DATOS GENERALES (F) TOTAL CF 1 2 3 4 5 6 7 8 9 10 11 12
AYMARA 0 0 0 0 0 0 0 0 0 0 0 0 0
QUECHUA 0 0 0 0 0 0 0 0 0 0 0 0 0
Hablado CASTELLANO #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
GUARANI #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
OTROS #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Idiomas
AYMARA #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
CASTELLANO #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Materno QUECHUA #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
GUARANI #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
OTROS #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
<1 #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
1-2 #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Kilometros
3-4 #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
>4 #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
< 30 minutos #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Distancia y tiempo desde la vivienda 30 - 50 minutos #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Tiempo a pie
hasta el establecimiento de salud 1 - 2 horas #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
>2 horas #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
< 30 minutos #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
30 - 50 minutos #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Tiempo en movilidad
1 - 2 horas #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
>2 horas #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Auxiliar en enfermeria #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Cargo del Responsable de llenado Licenciado(a) en enfermeria #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Médico(a) #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
IV. DETERMINANTES DE SALUD (F) TOTAL CF 1 2 3 4 5 6 7 8 9 10 11 12
1. Vivienda individual #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
2. Departamento #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
A. Tipo de vivienda 3. Cuartos o habitaciones sueltas #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
4. Choza/Pahuichi/casa rústica #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
5. Ambiente no destinado para habitar #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
1. Propia #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
2. Anticrética #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
B. Tenencia de 3. Alquiler #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Vivienda
4. Cuidador remunerado #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
5. Otros #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
1. Una o dos personas #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
2. Tres #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
C. No. de personas / 3. Cuatro #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
cuarto
4. cinco #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
5. Seis o más #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
IV. DETERMINANTES DE SALUD (F) TOTAL CF 1 2 3 4 5 6 7 8 9 10 11 12
1. Agua por cañería #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
2. Pileta pública #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
D. Abastecimiento de agua 3. Pozo/Noria/Vertiente/ Cisterna #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
4. Acequia/río #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
5.Charcos/ Atajados/Curichi #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
1. Servicio higiénico en domicilio #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
2. Servicio higiénico público #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
E. Eliminación de excretas 3. Letrina #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
4. Pozo ciego #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
5. Aire libre #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
1. Recojo domiciliario #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
2. Basura enterrada #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
F. Manejo de Basura 3. Calle/campo abierto #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
4. Quemado #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
5. Río/Quebrada #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
1. Le permite ahorrar #NAME? 0 0 0 0 0 0 0 0 0 0 0 0

G. Ingreso Familiar
 2. Satisface necesidades #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
G. Ingreso Familiar 3. Satisface necesidades básicas #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
4. A veces no alcanza #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
5. Insuficiente #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
1. Cons. diario de cereales, tuberculos y derivados #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
2. Consumo diario de alimentos de origen animal #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
H. Consumo diário de alimentos 3. Consumo diario de frutas y verduras #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
4. Consumo diario de aceite #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
5. Consumo diario de sal yodada. #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
1. Universitaria #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
2. Técnico #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
I. Nivel de Instrucción de la madre 3. Secundaria #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
4. Básica #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
5. Sin Instrucción #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Bajo 28 a 61 puntos #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Rango de riesgo Medio 62 a 126 puntos #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Alto 127 a 165 puntos #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
V. SALUD DE LOS INTEGRANTES DE LA FAMILIA (I) TOTAL CF 1 2 3 4 5 6 7 8 9 10 11 12
Nro DE INTEGRANTES DE LA FAMILIA #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Menores de 5 años #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Mujeres embarazadas #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Mayores de 60 años #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Habito de Fumar #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Obesidad #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Sedentarismo #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Factores de Alimentación no adecuada #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
riesgo
Promiscuidad #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Consumo excesivo de alcohol #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Consumo de drogas #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Problemas de salud
Higiene personal no adecuada #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Riesgos laborales #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Otros #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Tuberculosis(pulmonar y extrapulmonar) #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Lepra #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Enfermedad de Chagas #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Enfermedades VIH / SIDA #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Transmisibles
Leishmaniasis #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
hepatitis #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Otras #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Neoplasmas malignos #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Diabetes mellitus #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Hipertensión arterial #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Asma #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Enfermedades No Cardiopatias(isquèmica, hipertensiva, reumàtica) #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Transmisibles Enfermedades del Sistema locomotor(artrosis, artritis) #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Enfermedad pulmonar obstructiva crónica #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
(EPOC)
Insuficiencia renal crónica #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Desnutrición crónica #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Otras #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Intelectual #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Fisica #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Discapacidad
Sensorial #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Multiple #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
#NAME? 0 0 0 0 0 0 0 0 0 0 0 0
#NAME? 0 0 0 0 0 0 0 0 0 0 0 0
MASCULINO #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
5-9
FEMENINO #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
MASCULINO #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
10-19
FEMENINO #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Grupo de Riesgo I
MASCULINO #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
20-29
FEMENINO #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
MASCULINO #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
30-59
FEMENINO #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
#NAME? 0 0 0 0 0 0 0 0 0 0 0 0
#NAME? 0 0 0 0 0 0 0 0 0 0 0 0

Problemas de salud
 MASCULINO #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
<5
FEMENINO #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
MASCULINO #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
5-9
FEMENINO #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
MASCULINO #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Problemas de salud 10-19
Grupo de Riesgo FEMENINO #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
II MASCULINO #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
20-29
FEMENINO #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
MASCULINO #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
30-59
FEMENINO #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
MASCULINO #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
60 o +
FEMENINO #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
MASCULINO #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
<5
FEMENINO #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
MASCULINO #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
5-9
FEMENINO #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
MASCULINO #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
10-19
Grupo de Riesgo FEMENINO #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
III MASCULINO #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
20-29
FEMENINO #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
MASCULINO #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
30-59
FEMENINO #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
MASCULINO #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
60 o +
FEMENINO #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
MASCULINO #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
<5
FEMENINO #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
MASCULINO #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
5-9
FEMENINO #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
MASCULINO #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
10-19
Grupo de Riesgo FEMENINO #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
IV MASCULINO #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
20-29
FEMENINO #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
MASCULINO #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
30-59
FEMENINO #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
MASCULINO #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
60 o +
FEMENINO #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
VI. COMPORTAMIENTO FAMILIAR(F) TOTAL CF 1 2 3 4 5 6 7 8 9 10 11 12
Violencia intrafamiliar #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
ACTIVO #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Tabaquismo
PASIVO #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Maltrato infantil #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Consumo excesivo de alcohol #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Consumo de drogas #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
VII. EVALUACIÓN DEL COMPORTAMIENTO FAMILIAR(F) TOTAL CF 1 2 3 4 5 6 7 8 9 10 11 12
Funcional #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Disfuncional #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
VIII. RESULTADO DE LA EVALUACION DE LA SALUD FAMILIAR(F) TOTAL CF 1 2 3 4 5 6 7 8 9 10 11 12
Sin problema de salud #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Dificultades con los determinantes de salud #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Con problema de salud a predominio Dificultades con la salud de los integrantes de la familia
de: #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Dificultades en el funcionamiento de la familia #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
IX. FORMA DE AYUDA FAMILIAR NECESARIA(F) TOTAL CF 1 2 3 4 5 6 7 8 9 10 11 12
Ayuda Educativa #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Ayuda Terapéutica #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Ayuda Comunitaria #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
X. ASPECTOS SOCIOCULTURALES (I) TOTAL CF 1 2 3 4 5 6 7 8 9 10 11 12
Sí #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Residencia temporal
No #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Sí #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Lee No #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
No Corresponde #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Sí #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Escribe No #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
No Corresponde #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Primaria sin concluir #NAME? 0 0 0 0 0 0 0 0 0 0 0 0

Nivel de instrucción
 Primaria concluida #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Nivel de instrucción Secundaria concluida #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Técnico concluido #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Universitario concluido #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Directivos de gobierno y #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
empresas 14 o + #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Profesionales científicos e #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
intelectuales 14 o + #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Técnicos y profesionales de #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
nivel medio 14 o + #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
<14 #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Empleados de oficina y afines
14 o + #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Trabajo de servicios, <14 #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
vendedores y afines 14 o + #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Trabajos agrícolas, forestales y <14 #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
afines 14 o + #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Artesanos y operarios de <14 #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
oficios 14 o + #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Operarios de maquinas e <14 #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Ocupación instalaciones 14 o + #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Peones y trabajadores no <14 #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
calificados 14 o + #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
<14 #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Fuerzas armadas
14 o + #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
<14 #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Sin especificar u otros
14 o + #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
<14 #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Estudiante
14 o + #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
<14 #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Labores de casa
14 o + #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
#NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Jubilado o renta dignidad
14 o + #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
#NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Desempleado
14 o + #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Sí #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Contribuye a la economía familiar No #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
No corresponde #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
XI. MEDICINA TRADICIONAL(I) TOTAL CF 1 2 3 4 5 6 7 8 9 10 11 12
Siempre #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Recurre a la Medicina A veces #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Tradicional
Nunca #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
XII. NACIMIENTOS(I) TOTAL CF 1 2 3 4 5 6 7 8 9 10 11 12
Masculino #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Sexo
Femenino #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Dentro Establecimiento #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Parto
Fuera Establecimiento #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Personal establecimiento #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Atendido por Partera #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Familiar #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Sí #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
¿Tiene certificación de nacimiento?
No #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
XIII. DEFUNCIONES (I) TOTAL CF 1 2 3 4 5 6 7 8 9 10 11 12
Enero #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Febrero #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Marzo #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Abril #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Mayo #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Junio #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Defunciones por mes
Julio #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Agosto #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Septiembre #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Octubre #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Noviembre #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Diciembre #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Institucional #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Nro. de Defunciones
Nro. de Defunciones
No institucional #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Neonatal (< 28 días) #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Con Certificado de Defunción #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Médico #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Otorgado por Autoridad #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Otro #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Sin Certificado de Defunción #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
XIII. DEFUNCIONES (I) TOTAL CF 1 2 3 4 5 6 7 8 9 10 11 12
IRAs #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
EDAs #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Embarazo/ Parto/ Puerperio #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Malaria #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
TB #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Corazón #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Cáncer #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Causa Probable Accidente de Tránsito #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Accidente Laboral #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Homicidio #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Suicidio #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Intoxicaciones #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Mordedura de Ofidios #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Desconoce /No Sabe #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Otras #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
XIV. DATOS COMPLEMENTARIOS TOTAL CF 1 2 3 4 5 6 7 8 9 10 11 12
Nro. de niños menores Masculino #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
de 2 años Femenino
Desnutricion Aguda #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Moderada
Desnutricion Aguda #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Niños menores Sexo Masculino
Moderada #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
de 5 años Talla
Sexo Baja
Femenino
Sexo Masculino #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Talla Baja
Sexo Femenino #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Menor de 15 años #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
De 15 a 19 años #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Nro. de Puerperas
De 20 a 39 años #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Factores de riesgo Mayores de 40 años #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Dengue clásico #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Fiebre hemorrágica del Dengue #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Chagas #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Fiebre Amarilla #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Enfermedades Malaria #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Vectoriales
Leishmaniasis #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Chicungungunya #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Leptospirosis #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Otras enfermedades por vectores #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
XV. DATOS COMPLEMENTARIOS
TOTAL CF 1 2 3 4 5 6 7 8 9 10 11 12
(NRO. DE LOS INTEGRANTES DE LA FAMILIA POR RANGOS DE EDAD)
Neonatos Masculino #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
(28 dias) Femenino #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Menores de Masculino #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
1 año Femenino #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Niños de 1 año Masculino #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
a < 2 año Femenino #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Niños Masculino #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
de 2 a 4 años Femenino #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Personas Masculino #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
de 5 a 9 años Femenino #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Personas Masculino #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
de 10 a 14 años Femenino #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Personas Masculino #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
de 15 a 19 años Femenino #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Personas de Masculino #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
20 a 24 años Femenino #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Personas de Masculino #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
25 a 29 años Femenino #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Personas de Masculino #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
30 a 34 años Femenino #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Nro. DE INTEGRANTES DE Personas de Masculino #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
(GRUPO
LA FAMILIA
35 a 39 años

ETARIO
QUINQUENAL)
Nro. DE INTEGRANTES DE Personas de
(GRUPO
LA FAMILIA
35 a 39 años
Personas de
Femenino
Masculino
#NAME?
#NAME?
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
ETARIO 40 a 44 años
Personas de
Femenino
Masculino
#NAME?
#NAME?
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
QUINQUENAL) 45 a 49 años
Personas de
Femenino
Masculino
#NAME?
#NAME?
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
50 a 54 años Femenino #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Personas de Masculino #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
55 a 59 años Femenino #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Personas de Masculino #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
60 a 64 años Femenino #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Personas de Masculino #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
65 a 69 años Femenino #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Personas de Masculino #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
70 a 74 años Femenino #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Personas de Masculino #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
75 a 79 años Femenino #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Personas de Masculino #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
80 a 84 años Femenino #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Personas de Masculino #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
85 a 89 años Femenino #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Personas de Masculino #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
90 a 94 años Femenino #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
Personas Masculino #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
de 95 años y más Femenino #NAME? 0 0 0 0 0 0 0 0 0 0 0 0
 CONSOLIDADO N°1
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0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 1 2 3 4
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
 ESTABESIMIENTO:
CARPETAS FAMILIARES Completas y Baja Completa
Numeros de Seguimientos de Carpetas Familiares 0
I. DATOS GENERALES (F) TOTAL CF
AYMARA 0
QUECHUA 0
Hablado CASTELLANO 0
GUARANI 0
Idiomas
OTROS 0
AYMARA 0
CASTELLANO 0
Materno QUECHUA 0
GUARANI 0
OTROS 0
<1 0
Kilometros
1-2 0
3-4 0
>4 0
< 30 minutos 0
Distancia y tiempo desde la vivienda Tiempo a pie
30 - 50 minutos 0
hasta el establecimiento de salud 1 - 2 horas 0
>2 horas 0
< 30 minutos 0
Tiempo en movilidad
30 - 50 minutos 0
1 - 2 horas 0
>2 horas 0
Auxiliar en enfermeria 0
Cargo del Responsable de llenado Licenciado(a) en enfermeria 0
Médico(a) 0
IV. DETERMINANTES DE SALUD (F) TOTAL
1. Vivienda individual 5
2. Departamento 0
A. Tipo de vivienda 3. Cuartos o habitaciones sueltas 0
4. Choza/Pahuichi/casa rústica 0
5. Ambiente no destinado para habitar 0
1. Propia 1
2. Anticrética 0
B. Tenencia de
Vivienda 3. Alquiler 0
4. Cuidador remunerado 0
5. Otros 0
1. Una o dos personas 0
2. Tres 10
C. No. de personas /
cuarto 3. Cuatro 0
4. cinco 0
5. Seis o más 0
IV. DETERMINANTES DE SALUD (F) TOTAL
1. Agua por cañería 0
2. Pileta pública 0
D. Abastecimiento de agua 3. Pozo/Noria/Vertiente/ Cisterna 15
4. Acequia/río 0
5.Charcos/ Atajados/Curichi 0
1. Servicio higiénico en domicilio 0
2. Servicio higiénico público 0
E. Eliminación de excretas 3. Letrina 0
4. Pozo ciego 0
5. Aire libre 25
1. Recojo domiciliario 0
2. Basura enterrada 2
F. Manejo de Basura 3. Calle/campo abierto 0
4. Quemado 0
5. Río/Quebrada 0
1. Le permite ahorrar 0
2. Satisface necesidades 0
G. Ingreso Familiar 3. Satisface necesidades básicas 3
G. Ingreso Familiar
4. A veces no alcanza 0
5. Insuficiente 0
1. Cons. diario de cereales, tuberculos y derivados 5
2. Consumo diario de alimentos de origen animal 5
H. Consumo diário de alimentos 3. Consumo diario de frutas y verduras 5
4. Consumo diario de aceite 0
5. Consumo diario de sal yodada. 0
1. Universitaria 0
2. Técnico 0
I. Nivel de Instrucción de la madre 3. Secundaria 0
4. Básica 20
5. Sin Instrucción 0
Bajo 28 a 61 puntos 0
Rango de riesgo Medio 62 a 126 puntos 96
Alto 127 a 165 puntos 0
V. SALUD DE LOS INTEGRANTES DE LA FAMILIA (I) TOTAL
Nro DE INTEGRANTES DE LA FAMILIA 0
Menores de 5 años 2
Mujeres embarazadas 0
Mayores de 60 años 0
Habito de Fumar 0
Obesidad 0
Sedentarismo 0
Factores de
riesgo
Alimentación no adecuada 0
Promiscuidad 0
Consumo excesivo de alcohol 0
Problemas de salud
Consumo de drogas 0
Higiene personal no adecuada 0
Riesgos laborales 0
Otros 0
Tuberculosis(pulmonar y extrapulmonar) 0
Lepra 0
Enfermedad de Chagas 0
Enfermedades
Transmisibles
VIH / SIDA 0
Leishmaniasis 0
hepatitis 0
Otras 0
Neoplasmas malignos 0
Diabetes mellitus 0
Hipertensión arterial 0
Asma 0
Enfermedades No Cardiopatias(isquèmica, hipertensiva, reumàtica) 0
Transmisibles Enfermedades del Sistema locomotor(artrosis, artritis) 0
Enfermedad pulmonar obstructiva crónica
(EPOC)
0
Insuficiencia renal crónica 0
Desnutrición crónica 0
Otras 0
Intelectual 0
Discapacidad
Fisica 0
Sensorial 0
Multiple 0
0
0
5-9
MASCULINO 0
FEMENINO 0
10-19
MASCULINO 0
Grupo de Riesgo I
FEMENINO 0
20-29
MASCULINO 0
FEMENINO 0
30-59
MASCULINO 0
FEMENINO 0
0
0
<5
MASCULINO 0
FEMENINO 0
5-9
MASCULINO 0

Problemas de salud
Grupo de Riesgo
II
 5-9
FEMENINO 0
Problemas de salud 10-19
MASCULINO 0
Grupo de Riesgo FEMENINO 0
II
20-29
MASCULINO 0
FEMENINO 0
30-59
MASCULINO 0
FEMENINO 0
60 o +
MASCULINO 0
FEMENINO 0
 <5
MASCULINO 0
FEMENINO 0
5-9
MASCULINO 0
FEMENINO 0
10-19
MASCULINO 0
Grupo de Riesgo FEMENINO 0
III
20-29
MASCULINO 0
FEMENINO 0
30-59
MASCULINO 0
FEMENINO 0
60 o +
MASCULINO 0
FEMENINO 0
<5
MASCULINO 0
FEMENINO 0
5-9
MASCULINO 0
FEMENINO 0
10-19
MASCULINO 0
Grupo de Riesgo FEMENINO 0
IV
20-29
MASCULINO 0
FEMENINO 0
30-59
MASCULINO 0
FEMENINO 0
60 o +
MASCULINO 0
FEMENINO 0
VI. COMPORTAMIENTO FAMILIAR(F) TOTAL
Violencia intrafamiliar 0
Tabaquismo
ACTIVO 0
PASIVO 0
Maltrato infantil 0
Consumo excesivo de alcohol 0
Consumo de drogas 0
VII. EVALUACIÓN DEL COMPORTAMIENTO FAMILIAR(F) TOTAL
Funcional 0
Disfuncional 0
VIII. RESULTADO DE LA EVALUACION DE LA SALUD FAMILIAR(F) TOTAL
Sin problema de salud 0
Dificultades con los determinantes de salud 0
Con problema de salud a predominio
de:
Dificultades con la salud de los integrantes de la familia 0
Dificultades en el funcionamiento de la familia 0
IX. FORMA DE AYUDA FAMILIAR NECESARIA(F) TOTAL
Ayuda Educativa 0
Ayuda Terapéutica 0
Ayuda Comunitaria 0
X. ASPECTOS SOCIOCULTURALES (I) TOTAL
Residencia temporal
Sí 0
No 9
Sí 7
Lee No 0
No Corresponde 2
Sí 7
Escribe No 0
No Corresponde 2
Primaria sin concluir 0
Primaria concluida 5
Nivel de instrucción Secundaria concluida 2
Técnico concluido 1
Universitario concluido 0
Directivos de gobierno y 0
empresas 14 o + 0
Profesionales científicos e 0
intelectuales 14 o + 0
Técnicos y profesionales de 0
nivel medio 14 o + 0
Empleados de oficina y afines
<14 0
14 o + 0
Trabajo de servicios, <14 0
vendedores y afines

Ocupación
 Trabajo de servicios,
vendedores y afines 14 o + 0
Trabajos agrícolas, forestales y <14 0
afines 14 o + 0
Artesanos y operarios de <14 0
oficios 14 o + 0
Ocupación Operarios de maquinas e <14 0
instalaciones 14 o + 0
Peones y trabajadores no <14 0
calificados 14 o + 0
Fuerzas armadas
<14 0
14 o + 0
Sin especificar u otros
<14 0
14 o + 0
Estudiante
<14 0
14 o + 0
Labores de casa
<14 0
14 o + 0
Jubilado o renta dignidad
0
14 o + 0
Desempleado
0
14 o + 0
Sí 3
Contribuye a la economía familiar No 6
No corresponde 0
XI. MEDICINA TRADICIONAL(I) TOTAL
Siempre 0
Recurre a la Medicina
Tradicional A veces 3
Nunca 6
XII. NACIMIENTOS(I) TOTAL
Sexo
Masculino 0
Femenino 0
Parto
Dentro Establecimiento 0
Fuera Establecimiento 0
Personal establecimiento 0
Atendido por Partera 0
Familiar 0
¿Tiene certificación de nacimiento?
Sí 0
No 0
XIII. DEFUNCIONES (I) TOTAL
Enero 0
Febrero 0
Marzo 0
Abril 0
Mayo 0
Defunciones por mes
Junio 0
Julio 0
Agosto 0
Septiembre 0
Octubre 0
Noviembre 0
Diciembre 0
Nro. de Defunciones
Institucional 0
No institucional 0
Neonatal (< 28 días) 0
Con Certificado de Defunción 0
Médico 0
Otorgado por Autoridad 0
Otro 0
Sin Certificado de Defunción 0
XIII. DEFUNCIONES (I) TOTAL
IRAs 0
EDAs 0
Embarazo/ Parto/ Puerperio 0
Malaria 0
TB 0
Corazón 0
Causa Probable
 Cáncer 0
Causa Probable Accidente de Tránsito 0
Accidente Laboral 0
Homicidio 0
Suicidio 0
Intoxicaciones 0
Mordedura de Ofidios 0
Desconoce /No Sabe 0
Otras 0
XIV. DATOS COMPLEMENTARIOS Desnutricion Aguda TOTAL
Moderada
Desnutricion Aguda 0
Niños menores Sexo Masculino
Moderada 0
Talla
Sexo Baja
Femenino
de 5 años
Sexo Baja
Masculino 0
Talla
Sexo Femenino 0
Menor de 15 años 0
Nro. de Puerperas
De 15 a 19 años 0
De 20 a 39 años 0
Mayores de 40 años 0
Factores de riesgo Dengue clásico 0
Fiebre hemorrágica del Dengue 0
Chagas 0
Fiebre Amarilla 0
Enfermedades
Vectoriales Malaria 0
Leishmaniasis 0
Chicungungunya 0
Leptospirosis 0
Otras enfermedades por vectores 0
XV. DATOS COMPLEMENTARIOS
(NRO. DE LOS INTEGRANTES DE LA FAMILIA POR RANGOS DE EDAD) TOTAL
Neonatos Masculino 0
(28 dias) Femenino 0
Menores de Masculino 0
1 año Femenino 0
Niños de 1 año Masculino 0
a < 2 año Femenino 0
Niños Masculino 0
de 2 a 4 años Femenino 0
Personas Masculino 0
de 5 a 9 años Femenino 0
Personas Masculino 0
de 10 a 14 años Femenino 0
Personas Masculino 0
de 15 a 19 años Femenino 0
Personas de Masculino 0
20 a 24 años Femenino 0
Personas de Masculino 0
25 a 29 años Femenino 0
Personas de Masculino 0
30 a 34 años Femenino 0
Nro. DE INTEGRANTES DE Personas de Masculino 0
(GRUPO
LA FAMILIA
35 a 39 años
Personas de
Femenino
Masculino
0
0
ETARIO 40 a 44 años
Personas de
Femenino
Masculino
0
0
QUINQUENAL) 45 a 49 años
Personas de
Femenino
Masculino
0
0
50 a 54 años Femenino 0
Personas de Masculino 0
55 a 59 años Femenino 0
Personas de Masculino 0
60 a 64 años Femenino 0
Personas de Masculino 0
65 a 69 años Femenino 0
Personas de Masculino 0
70 a 74 años Femenino 0
Personas de Masculino 0
75 a 79 años Femenino 0
 Personas de Masculino 0
80 a 84 años Femenino 0
Personas de Masculino 0
85 a 89 años Femenino 0
Personas de Masculino 0
90 a 94 años Femenino 0
Personas Masculino 0
de 95 años y más Femenino 0
 INSTRUMENTO DE SISTEMATIZACIÓN ANUAL DE LA CARPETA F
Año: ________________ SEDES__________________ Municipio: _____________________________________ Red de Salud: ______________________________________________
Ambito Geográfico: Urbano Rural Establecimiento: _______________________________________________________
Número de Carpetas Revisadas Comunidad/Localidad/Ciudad/Distrito:

Numeros de Seguimientos de Carpetas Familiares

CARPETAS FAMILIARES Bajas
I. DATOS GENERALES (F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
AYMARA
QUECHUA
Hablado CASTELLANO
GUARANI
OTROS
Idiomas
AYMARA
CASTELLANO
Materno QUECHUA
GUARANI
OTROS
<1
1-2
Kilometros
3-4
>4
< 30 minutos
Distancia y tiempo desde la vivienda 30 - 50 minutos
Tiempo a pie
hasta el establecimiento de salud 1 - 2 horas
>2 horas
< 30 minutos
30 - 50 minutos
Tiempo en movilidad
1 - 2 horas
>2 horas
Auxiliar en enfermeria
Cargo del Responsable de llenado Licenciado(a) en enfermeria
Médico(a)
IV. DETERMINANTES DE SALUD (F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
1. Vivienda individual
2. Departamento
A. Tipo de vivienda 3. Cuartos o habitaciones sueltas
4. Choza/Pahuichi/casa rústica
5. Ambiente no destinado para habitar
1. Propia
2. Anticrética
B. Tenencia de 3. Alquiler
Vivienda
4. Cuidador remunerado
5. Otros
1. Una o dos personas
2. Tres
C. No. de personas / 3. Cuatro
cuarto
4. cinco
C. No. de personas /
cuarto
IV. DETERMINANTES DE SALUD (F)
D. Abastecimiento de agua
E. Eliminación de excretas
F. Manejo de Basura
G. Ingreso Familiar
H. Consumo diário de alimentos
I. Nivel de Instrucción de la madre
Rango de riesgo
5. Seis o más
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
1. Agua por cañería
2. Pileta pública
3. Pozo/Noria/Vertiente/ Cisterna
4. Acequia/río
5.Charcos/ Atajados/Curichi
1. Servicio higiénico en domicilio
2. Servicio higiénico público
3. Letrina
4. Pozo ciego
5. Aire libre
1. Recojo domiciliario
2. Basura enterrada
3. Calle/campo abierto
4. Quemado
5. Río/Quebrada
1. Le permite ahorrar
2. Satisface necesidades
3. Satisface necesidades básicas
4. A veces no alcanza
5. Insuficiente
1. Cons. diario de cereales, tuberculos y derivados
2. Consumo diario de alimentos de origen animal
3. Consumo diario de frutas y verduras
4. Consumo diario de aceite
5. Consumo diario de sal yodada.
1. Universitaria
2. Técnico
3. Secundaria
4. Básica
5. Sin Instrucción
Bajo 28 a 61 puntos
Medio 62 a 126 puntos
Alto 127 a 165 puntos
V. SALUD DE LOS INTEGRANTES DE LA FAMILIA (I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Nro DE INTEGRANTES DE LA FAMILIA
Menores de 5 años 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Mujeres embarazadas
Mayores de 60 años 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Habito de Fumar
Obesidad
Sedentarismo
Factores de Alimentación no adecuada
riesgo
Promiscuidad
Consumo excesivo de alcohol
Consumo de drogas
Problemas de salud
Higiene personal no adecuada
Riesgos laborales
Otros
Tuberculosis(pulmonar y extrapulmonar)
Lepra
Enfermedad de Chagas
Enfermedades VIH / SIDA
Transmisibles
Leishmaniasis
hepatitis
Otras
Neoplasmas malignos
Diabetes mellitus
Hipertensión arterial
Asma
Enfermedades No Cardiopatias(isquèmica, hipertensiva, reumàtica)
Transmisibles Enfermedades del Sistema locomotor(artrosis, artritis)
Enfermedad pulmonar obstructiva crónica
(EPOC)
Insuficiencia renal crónica
Desnutrición crónica
Otras
Intelectual
Fisica
Discapacidad
Sensorial
Multiple

MASCULINO
5-9
FEMENINO
MASCULINO
10-19
FEMENINO
Grupo de Riesgo I
MASCULINO
20-29
FEMENINO
MASCULINO
30-59
FEMENINO
 MASCULINO
<5
FEMENINO
MASCULINO
5-9
FEMENINO
MASCULINO
Problemas de salud 10-19
Grupo de Riesgo FEMENINO
II MASCULINO
20-29
FEMENINO
MASCULINO
30-59
FEMENINO
MASCULINO
60 o +
FEMENINO
MASCULINO
<5
FEMENINO
MASCULINO
5-9
FEMENINO
MASCULINO
10-19
Grupo de Riesgo FEMENINO
III MASCULINO
20-29
FEMENINO
MASCULINO
30-59
FEMENINO
MASCULINO
60 o +
FEMENINO
MASCULINO
<5
FEMENINO
MASCULINO
5-9
FEMENINO
MASCULINO
10-19
Grupo de Riesgo FEMENINO
IV MASCULINO
20-29
FEMENINO
MASCULINO
30-59
FEMENINO
MASCULINO
60 o +
FEMENINO
VI. COMPORTAMIENTO FAMILIAR(F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Violencia intrafamiliar
ACTIVO
Tabaquismo
PASIVO
Maltrato infantil
Consumo excesivo de alcohol
Consumo de drogas
VII. EVALUACIÓN DEL COMPORTAMIENTO FAMILIAR(F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Funcional
Disfuncional
VIII. RESULTADO DE LA EVALUACION DE LA SALUD FAMILIAR(F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Sin problema de salud
Dificultades con los determinantes de salud
Con problema de salud a predominio Dificultades con la salud de los integrantes de la familia
de:
Dificultades en el funcionamiento de la familia

IX. FORMA DE AYUDA FAMILIAR NECESARIA(F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29

Ayuda Educativa
Ayuda Terapéutica
Ayuda Comunitaria
X. ASPECTOS SOCIOCULTURALES (I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Sí
Residencia temporal
No
Sí
Lee No
No Corresponde
Sí 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Escribe No 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
No Corresponde 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Primaria sin concluir
Primaria concluida
Nivel de instrucción Secundaria concluida
Técnico concluido
Universitario concluido
Directivos de gobierno y
empresas 14 o +
Profesionales científicos e
intelectuales
14 o +
Técnicos y profesionales de
nivel medio 14 o +
<14
Empleados de oficina y afines
14 o +
Trabajo de servicios, <14
vendedores y afines 14 o +
Trabajos agrícolas, forestales y <14
afines
14 o +
Artesanos y operarios de <14
oficios 14 o +
Operarios de maquinas e <14
Ocupación instalaciones
 Operarios de maquinas e
Ocupación instalaciones
14 o +
Peones y trabajadores no <14
calificados
14 o +
<14
Fuerzas armadas
14 o +
<14
Sin especificar u otros
14 o +
<14
Estudiante
14 o +
<14
Labores de casa
14 o +

Jubilado o renta dignidad

14 o +

Desempleado
14 o +
Sí
Contribuye a la economía familiar No
No corresponde
XI. MEDICINA TRADICIONAL(I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Siempre
Recurre a la Medicina A veces
Tradicional
Nunca
XII. NACIMIENTOS(I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Masculino
Sexo
Femenino
Dentro Establecimiento
Parto
Fuera Establecimiento
Personal establecimiento
Atendido por Partera
Familiar
Sí
¿Tiene certificación de nacimiento?
No
XIII. DEFUNCIONES (I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Enero
Febrero
Marzo
Abril
Mayo
Junio
Defunciones por mes
Julio
Agosto
Septiembre
Octubre
Noviembre
Diciembre
Institucional
Nro. de Defunciones
No institucional
Neonatal (< 28 días)
Con Certificado de Defunción
Médico
Otorgado por Autoridad
Otro
Sin Certificado de Defunción
XIII. DEFUNCIONES (I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
IRAs
EDAs
Embarazo/ Parto/ Puerperio
Malaria
TB
Corazón
Cáncer
Causa Probable Accidente de Tránsito
Accidente Laboral
Homicidio
Suicidio
Intoxicaciones
Mordedura de Ofidios
Desconoce /No Sabe
Otras
CARPETA FAMILIAR
_________

30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL

0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
 0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0
0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0
0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0
0 0
0 0
0 0
0 0
0
0 0
0
0 0
0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
 0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0
0 0
0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
 INSTRUMENTO DE SISTEMATIZACIÓN ANUAL DE LA CARPETA F
Año: ________________ SEDES__________________ Municipio: _____________________________________ Red de Salud: ______________________________________________
Ambito Geográfico: Urbano Rural Establecimiento: _______________________________________________________
Número de Carpetas Revisadas Comunidad/Localidad/Ciudad/Distrito:

Numeros de Seguimientos de Carpetas Familiares

CARPETAS FAMILIARES Completas, Parciales
I. DATOS GENERALES (F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
AYMARA
QUECHUA
Hablado CASTELLANO
GUARANI
OTROS
Idiomas
AYMARA
CASTELLANO
Materno QUECHUA
GUARANI
OTROS
<1
1-2
Kilometros
3-4
>4
< 30 minutos
Distancia y tiempo desde la vivienda 30 - 50 minutos
Tiempo a pie
hasta el establecimiento de salud 1 - 2 horas
>2 horas
< 30 minutos
30 - 50 minutos
Tiempo en movilidad
1 - 2 horas
>2 horas
Auxiliar en enfermeria
Cargo del Responsable de llenado Licenciado(a) en enfermeria
Médico(a)
IV. DETERMINANTES DE SALUD (F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
1. Vivienda individual
2. Departamento
A. Tipo de vivienda 3. Cuartos o habitaciones sueltas
4. Choza/Pahuichi/casa rústica
5. Ambiente no destinado para habitar
1. Propia
2. Anticrética
B. Tenencia de 3. Alquiler
Vivienda
4. Cuidador remunerado
5. Otros
1. Una o dos personas
2. Tres
C. No. de personas / 3. Cuatro
cuarto
4. cinco
C. No. de personas /
cuarto
IV. DETERMINANTES DE SALUD (F)
D. Abastecimiento de agua
E. Eliminación de excretas
F. Manejo de Basura
G. Ingreso Familiar
H. Consumo diário de alimentos
I. Nivel de Instrucción de la madre
Rango de riesgo
5. Seis o más
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
1. Agua por cañería
2. Pileta pública
3. Pozo/Noria/Vertiente/ Cisterna
4. Acequia/río
5.Charcos/ Atajados/Curichi
1. Servicio higiénico en domicilio
2. Servicio higiénico público
3. Letrina
4. Pozo ciego
5. Aire libre
1. Recojo domiciliario
2. Basura enterrada
3. Calle/campo abierto
4. Quemado
5. Río/Quebrada
1. Le permite ahorrar
2. Satisface necesidades
3. Satisface necesidades básicas
4. A veces no alcanza
5. Insuficiente
1. Cons. diario de cereales, tuberculos y derivados
2. Consumo diario de alimentos de origen animal
3. Consumo diario de frutas y verduras
4. Consumo diario de aceite
5. Consumo diario de sal yodada.
1. Universitaria
2. Técnico
3. Secundaria
4. Básica
5. Sin Instrucción
Bajo 28 a 61 puntos
Medio 62 a 126 puntos
Alto 127 a 165 puntos
V. SALUD DE LOS INTEGRANTES DE LA FAMILIA (I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Nro DE INTEGRANTES DE LA FAMILIA
Menores de 5 años 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Mujeres embarazadas
Mayores de 60 años 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Habito de Fumar
Obesidad
Sedentarismo
Factores de Alimentación no adecuada
riesgo
Promiscuidad
Consumo excesivo de alcohol
Consumo de drogas
Problemas de salud
Higiene personal no adecuada
Riesgos laborales
Otros
Tuberculosis(pulmonar y extrapulmonar)
Lepra
Enfermedad de Chagas
Enfermedades VIH / SIDA
Transmisibles
Leishmaniasis
hepatitis
Otras
Neoplasmas malignos
Diabetes mellitus
Hipertensión arterial
Asma
Enfermedades No Cardiopatias(isquèmica, hipertensiva, reumàtica)
Transmisibles Enfermedades del Sistema locomotor(artrosis, artritis)
Enfermedad pulmonar obstructiva crónica
(EPOC)
Insuficiencia renal crónica
Desnutrición crónica
Otras
Intelectual
Fisica
Discapacidad
Sensorial
Multiple

MASCULINO
5-9
FEMENINO
MASCULINO
10-19
FEMENINO
Grupo de Riesgo I
MASCULINO
20-29
FEMENINO
MASCULINO
30-59
FEMENINO
 MASCULINO
<5
FEMENINO
MASCULINO
5-9
FEMENINO
MASCULINO
Problemas de salud 10-19
Grupo de Riesgo FEMENINO
II MASCULINO
20-29
FEMENINO
MASCULINO
30-59
FEMENINO
MASCULINO
60 o +
FEMENINO
MASCULINO
<5
FEMENINO
MASCULINO
5-9
FEMENINO
MASCULINO
10-19
Grupo de Riesgo FEMENINO
III MASCULINO
20-29
FEMENINO
MASCULINO
30-59
FEMENINO
MASCULINO
60 o +
FEMENINO
MASCULINO
<5
FEMENINO
MASCULINO
5-9
FEMENINO
MASCULINO
10-19
Grupo de Riesgo FEMENINO
IV MASCULINO
20-29
FEMENINO
MASCULINO
30-59
FEMENINO
MASCULINO
60 o +
FEMENINO
VI. COMPORTAMIENTO FAMILIAR(F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Violencia intrafamiliar
ACTIVO
Tabaquismo
PASIVO
Maltrato infantil
Consumo excesivo de alcohol
Consumo de drogas
VII. EVALUACIÓN DEL COMPORTAMIENTO FAMILIAR(F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Funcional
Disfuncional
VIII. RESULTADO DE LA EVALUACION DE LA SALUD FAMILIAR(F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Sin problema de salud
Dificultades con los determinantes de salud
Con problema de salud a predominio Dificultades con la salud de los integrantes de la familia
de:
Dificultades en el funcionamiento de la familia

IX. FORMA DE AYUDA FAMILIAR NECESARIA(F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29

Ayuda Educativa
Ayuda Terapéutica
Ayuda Comunitaria
X. ASPECTOS SOCIOCULTURALES (I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Sí
Residencia temporal
No
Sí
Lee No
No Corresponde
Sí 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Escribe No 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
No Corresponde 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Primaria sin concluir
Primaria concluida
Nivel de instrucción Secundaria concluida
Técnico concluido
Universitario concluido
Directivos de gobierno y
empresas 14 o +
Profesionales científicos e
intelectuales
14 o +
Técnicos y profesionales de
nivel medio 14 o +
<14
Empleados de oficina y afines
14 o +
Trabajo de servicios, <14
vendedores y afines 14 o +
Trabajos agrícolas, forestales y <14
afines
14 o +
Artesanos y operarios de <14
oficios 14 o +
Operarios de maquinas e <14
Ocupación instalaciones
 Operarios de maquinas e
Ocupación instalaciones
14 o +
Peones y trabajadores no <14
calificados
14 o +
<14
Fuerzas armadas
14 o +
<14
Sin especificar u otros
14 o +
<14
Estudiante
14 o +
<14
Labores de casa
14 o +

Jubilado o renta dignidad

14 o +

Desempleado
14 o +
Sí
Contribuye a la economía familiar No
No corresponde
XI. MEDICINA TRADICIONAL(I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Siempre
Recurre a la Medicina A veces
Tradicional
Nunca
XII. NACIMIENTOS(I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Masculino
Sexo
Femenino
Dentro Establecimiento
Parto
Fuera Establecimiento
Personal establecimiento
Atendido por Partera
Familiar
Sí
¿Tiene certificación de nacimiento?
No
XIII. DEFUNCIONES (I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Enero
Febrero
Marzo
Abril
Mayo
Junio
Defunciones por mes
Julio
Agosto
Septiembre
Octubre
Noviembre
Diciembre
Institucional
Nro. de Defunciones
No institucional
Neonatal (< 28 días)
Con Certificado de Defunción
Médico
Otorgado por Autoridad
Otro
Sin Certificado de Defunción
XIII. DEFUNCIONES (I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
IRAs
EDAs
Embarazo/ Parto/ Puerperio
Malaria
TB
Corazón
Cáncer
Causa Probable Accidente de Tránsito
Accidente Laboral
Homicidio
Suicidio
Intoxicaciones
Mordedura de Ofidios
Desconoce /No Sabe
Otras
CARPETA FAMILIAR
_________

30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL

0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
 0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0
0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0
0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0
0 0
0 0
0 0
0 0
0
0 0
0
0 0
0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
 0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0
0 0
0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
 INSTRUMENTO DE SISTEMATIZACIÓN ANUAL DE LA CARPETA F
Año: ________________ SEDES__________________ Municipio: _____________________________________ Red de Salud: ______________________________________________
Ambito Geográfico: Urbano Rural Establecimiento: _______________________________________________________
Número de Carpetas Revisadas Comunidad/Localidad/Ciudad/Distrito:
Numeros de Seguimientos de Carpetas Familiares
CARPETAS Completas, Parciales, Bajas
I. DATOS GENERALES (F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
AYMARA
QUECHUA
Hablado CASTELLANO
GUARANI
OTROS
Idiomas
AYMARA
CASTELLANO
Materno QUECHUA
GUARANI
OTROS
<1
1-2
Kilometros
3-4
>4
< 30 minutos
Distancia y tiempo desde la vivienda 30 - 50 minutos
Tiempo a pie
hasta el establecimiento de salud 1 - 2 horas
>2 horas
< 30 minutos
30 - 50 minutos
Tiempo en movilidad
1 - 2 horas
>2 horas
Auxiliar en enfermeria
Cargo del Responsable de llenado Licenciado(a) en enfermeria
Médico(a)
IV. DETERMINANTES DE SALUD (F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
1. Vivienda individual
2. Departamento
A. Tipo de vivienda 3. Cuartos o habitaciones sueltas
4. Choza/Pahuichi/casa rústica
5. Ambiente no destinado para habitar
1. Propia
2. Anticrética
B. Tenencia de 3. Alquiler
Vivienda
4. Cuidador remunerado
5. Otros
1. Una o dos personas
2. Tres
C. No. de personas / 3. Cuatro
cuarto
4. cinco
5. Seis o más
IV. DETERMINANTES DE SALUD (F)
D. Abastecimiento de agua
E. Eliminación de excretas
F. Manejo de Basura
G. Ingreso Familiar
H. Consumo diário de alimentos
I. Nivel de Instrucción de la madre
Rango de riesgo
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
1. Agua por cañería
2. Pileta pública
3. Pozo/Noria/Vertiente/ Cisterna
4. Acequia/río
5.Charcos/ Atajados/Curichi
1. Servicio higiénico en domicilio
2. Servicio higiénico público
3. Letrina
4. Pozo ciego
5. Aire libre
1. Recojo domiciliario
2. Basura enterrada
3. Calle/campo abierto
4. Quemado
5. Río/Quebrada
1. Le permite ahorrar
2. Satisface necesidades
3. Satisface necesidades básicas
4. A veces no alcanza
5. Insuficiente
1. Cons. diario de cereales, tuberculos y derivados
2. Consumo diario de alimentos de origen animal
3. Consumo diario de frutas y verduras
4. Consumo diario de aceite
5. Consumo diario de sal yodada.
1. Universitaria
2. Técnico
3. Secundaria
4. Básica
5. Sin Instrucción
Bajo 28 a 61 puntos
Medio 62 a 126 puntos
Alto 127 a 165 puntos
V. SALUD DE LOS INTEGRANTES DE LA FAMILIA (I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Nro DE INTEGRANTES DE LA FAMILIA
Menores de 5 años 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Mujeres embarazadas
Mayores de 60 años 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Habito de Fumar
Obesidad
Sedentarismo
Factores de Alimentación no adecuada
riesgo
Promiscuidad
Consumo excesivo de alcohol
Consumo de drogas
Problemas de salud
Higiene personal no adecuada
Riesgos laborales
Otros
Tuberculosis(pulmonar y extrapulmonar)
Lepra
Enfermedad de Chagas
Enfermedades VIH / SIDA
Transmisibles
Leishmaniasis
hepatitis
Otras
Neoplasmas malignos
Diabetes mellitus
Hipertensión arterial
Asma
Enfermedades No Cardiopatias(isquèmica, hipertensiva, reumàtica)
Transmisibles Enfermedades del Sistema locomotor(artrosis, artritis)
Enfermedad pulmonar obstructiva crónica
(EPOC)
Insuficiencia renal crónica
Desnutrición crónica
Otras
Intelectual
Fisica
Discapacidad
Sensorial
Multiple

MASCULINO
5-9
FEMENINO
MASCULINO
10-19
FEMENINO
Grupo de Riesgo I
MASCULINO
20-29
FEMENINO
MASCULINO
30-59
FEMENINO
 MASCULINO
<5
FEMENINO
MASCULINO
5-9
FEMENINO
MASCULINO
Problemas de salud 10-19
Grupo de Riesgo FEMENINO
II MASCULINO
20-29
FEMENINO
MASCULINO
30-59
FEMENINO
MASCULINO
60 o +
FEMENINO
MASCULINO
<5
FEMENINO
MASCULINO
5-9
FEMENINO
MASCULINO
10-19
Grupo de Riesgo FEMENINO
III MASCULINO
20-29
FEMENINO
MASCULINO
30-59
FEMENINO
MASCULINO
60 o +
FEMENINO
MASCULINO
<5
FEMENINO
MASCULINO
5-9
FEMENINO
MASCULINO
10-19
Grupo de Riesgo FEMENINO
IV MASCULINO
20-29
FEMENINO
MASCULINO
30-59
FEMENINO
MASCULINO
60 o +
FEMENINO
VI. COMPORTAMIENTO FAMILIAR(F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Violencia intrafamiliar
ACTIVO
Tabaquismo
PASIVO
Maltrato infantil
Consumo excesivo de alcohol
Consumo de drogas
VII. EVALUACIÓN DEL COMPORTAMIENTO FAMILIAR(F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Funcional
Disfuncional
VIII. RESULTADO DE LA EVALUACION DE LA SALUD FAMILIAR(F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Sin problema de salud
Dificultades con los determinantes de salud
Con problema de salud a predominio Dificultades con la salud de los integrantes de la familia
de:
Dificultades en el funcionamiento de la familia

IX. FORMA DE AYUDA FAMILIAR NECESARIA(F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29

Ayuda Educativa
Ayuda Terapéutica
Ayuda Comunitaria
X. ASPECTOS SOCIOCULTURALES (I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Sí
Residencia temporal
No
Sí
Lee No
No Corresponde
Sí 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Escribe No 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
No Corresponde 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Primaria sin concluir
Primaria concluida
Nivel de instrucción Secundaria concluida
Técnico concluido
Universitario concluido
Directivos de gobierno y
empresas 14 o +
Profesionales científicos e
intelectuales
14 o +
Técnicos y profesionales de
nivel medio 14 o +
<14
Empleados de oficina y afines
14 o +
Trabajo de servicios, <14
vendedores y afines 14 o +
Trabajos agrícolas, forestales y <14
afines
14 o +
Artesanos y operarios de <14
oficios 14 o +
Operarios de maquinas e <14
Ocupación instalaciones
 Operarios de maquinas e
Ocupación instalaciones
14 o +
Peones y trabajadores no <14
calificados
14 o +
<14
Fuerzas armadas
14 o +
<14
Sin especificar u otros
14 o +
<14
Estudiante
14 o +
<14
Labores de casa
14 o +

Jubilado o renta dignidad

14 o +

Desempleado
14 o +
Sí
Contribuye a la economía familiar No
No corresponde
XI. MEDICINA TRADICIONAL(I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Siempre
Recurre a la Medicina A veces
Tradicional
Nunca
XII. NACIMIENTOS(I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Masculino
Sexo
Femenino
Dentro Establecimiento
Parto
Fuera Establecimiento
Personal establecimiento
Atendido por Partera
Familiar
Sí
¿Tiene certificación de nacimiento?
No
XIII. DEFUNCIONES (I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Enero
Febrero
Marzo
Abril
Mayo
Junio
Defunciones por mes
Julio
Agosto
Septiembre
Octubre
Noviembre
Diciembre
Institucional
Nro. de Defunciones
No institucional
Neonatal (< 28 días)
Con Certificado de Defunción
Médico
Otorgado por Autoridad
Otro
Sin Certificado de Defunción
XIII. DEFUNCIONES (I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
IRAs
EDAs
Embarazo/ Parto/ Puerperio
Malaria
TB
Corazón
Cáncer
Causa Probable Accidente de Tránsito
Accidente Laboral
Homicidio
Suicidio
Intoxicaciones
Mordedura de Ofidios
Desconoce /No Sabe
Otras
CARPETA FAMILIAR
_________

30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL

0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0
0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0
0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0
0 0
0 0
0 0
0 0
0
0 0
0
0 0
0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
 0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0
0 0
0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
 INSTRUMENTO DE SISTEMATIZACIÓN ANUAL DE LA CARPETA F
Año: ________________ SEDES__________________ Municipio: _____________________________________ Red de Salud: ______________________________________________
Ambito Geográfico: Urbano Rural Establecimiento: _______________________________________________________
Número de Carpetas Revisadas Comunidad/Localidad/Ciudad/Distrito:
Numeros de Seguimientos de Carpetas Familiares
CARPETAS Completas, Parciales, Bajas
I. DATOS GENERALES (F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
AYMARA
QUECHUA
Hablado CASTELLANO
GUARANI
OTROS
Idiomas
AYMARA
CASTELLANO
Materno QUECHUA
GUARANI
OTROS
<1
1-2
Kilometros
3-4
>4
< 30 minutos
Distancia y tiempo desde la vivienda 30 - 50 minutos
Tiempo a pie
hasta el establecimiento de salud 1 - 2 horas
>2 horas
< 30 minutos
30 - 50 minutos
Tiempo en movilidad
1 - 2 horas
>2 horas
Auxiliar en enfermeria
Cargo del Responsable de llenado Licenciado(a) en enfermeria
Médico(a)
IV. DETERMINANTES DE SALUD (F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
1. Vivienda individual
2. Departamento
A. Tipo de vivienda 3. Cuartos o habitaciones sueltas
4. Choza/Pahuichi/casa rústica
5. Ambiente no destinado para habitar
1. Propia
2. Anticrética
B. Tenencia de 3. Alquiler
Vivienda
4. Cuidador remunerado
5. Otros
1. Una o dos personas
2. Tres
C. No. de personas / 3. Cuatro
cuarto
4. cinco
5. Seis o más
IV. DETERMINANTES DE SALUD (F)
D. Abastecimiento de agua
E. Eliminación de excretas
F. Manejo de Basura
G. Ingreso Familiar
H. Consumo diário de alimentos
I. Nivel de Instrucción de la madre
Rango de riesgo
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
1. Agua por cañería
2. Pileta pública
3. Pozo/Noria/Vertiente/ Cisterna
4. Acequia/río
5.Charcos/ Atajados/Curichi
1. Servicio higiénico en domicilio
2. Servicio higiénico público
3. Letrina
4. Pozo ciego
5. Aire libre
1. Recojo domiciliario
2. Basura enterrada
3. Calle/campo abierto
4. Quemado
5. Río/Quebrada
1. Le permite ahorrar
2. Satisface necesidades
3. Satisface necesidades básicas
4. A veces no alcanza
5. Insuficiente
1. Cons. diario de cereales, tuberculos y derivados
2. Consumo diario de alimentos de origen animal
3. Consumo diario de frutas y verduras
4. Consumo diario de aceite
5. Consumo diario de sal yodada.
1. Universitaria
2. Técnico
3. Secundaria
4. Básica
5. Sin Instrucción
Bajo 28 a 61 puntos
Medio 62 a 126 puntos
Alto 127 a 165 puntos
V. SALUD DE LOS INTEGRANTES DE LA FAMILIA (I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Nro DE INTEGRANTES DE LA FAMILIA
Menores de 5 años 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Mujeres embarazadas
Mayores de 60 años 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Habito de Fumar
Obesidad
Sedentarismo
Factores de Alimentación no adecuada
riesgo
Promiscuidad
Consumo excesivo de alcohol
Consumo de drogas
Problemas de salud
Higiene personal no adecuada
Riesgos laborales
Otros
Tuberculosis(pulmonar y extrapulmonar)
Lepra
Enfermedad de Chagas
Enfermedades VIH / SIDA
Transmisibles
Leishmaniasis
hepatitis
Otras
Neoplasmas malignos
Diabetes mellitus
Hipertensión arterial
Asma
Enfermedades No Cardiopatias(isquèmica, hipertensiva, reumàtica)
Transmisibles Enfermedades del Sistema locomotor(artrosis, artritis)
Enfermedad pulmonar obstructiva crónica
(EPOC)
Insuficiencia renal crónica
Desnutrición crónica
Otras
Intelectual
Fisica
Discapacidad
Sensorial
Multiple

MASCULINO
5-9
FEMENINO
MASCULINO
10-19
FEMENINO
Grupo de Riesgo I
MASCULINO
20-29
FEMENINO
MASCULINO
30-59
FEMENINO
 MASCULINO
<5
FEMENINO
MASCULINO
5-9
FEMENINO
MASCULINO
Problemas de salud 10-19
Grupo de Riesgo FEMENINO
II MASCULINO
20-29
FEMENINO
MASCULINO
30-59
FEMENINO
MASCULINO
60 o +
FEMENINO
MASCULINO
<5
FEMENINO
MASCULINO
5-9
FEMENINO
MASCULINO
10-19
Grupo de Riesgo FEMENINO
III MASCULINO
20-29
FEMENINO
MASCULINO
30-59
FEMENINO
MASCULINO
60 o +
FEMENINO
MASCULINO
<5
FEMENINO
MASCULINO
5-9
FEMENINO
MASCULINO
10-19
Grupo de Riesgo FEMENINO
IV MASCULINO
20-29
FEMENINO
MASCULINO
30-59
FEMENINO
MASCULINO
60 o +
FEMENINO
VI. COMPORTAMIENTO FAMILIAR(F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Violencia intrafamiliar
ACTIVO
Tabaquismo
PASIVO
Maltrato infantil
Consumo excesivo de alcohol
Consumo de drogas
VII. EVALUACIÓN DEL COMPORTAMIENTO FAMILIAR(F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Funcional
Disfuncional
VIII. RESULTADO DE LA EVALUACION DE LA SALUD FAMILIAR(F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Sin problema de salud
Dificultades con los determinantes de salud
Con problema de salud a predominio Dificultades con la salud de los integrantes de la familia
de:
Dificultades en el funcionamiento de la familia

IX. FORMA DE AYUDA FAMILIAR NECESARIA(F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29

Ayuda Educativa
Ayuda Terapéutica
Ayuda Comunitaria
X. ASPECTOS SOCIOCULTURALES (I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Sí
Residencia temporal
No
Sí
Lee No
No Corresponde
Sí 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Escribe No 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
No Corresponde 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Primaria sin concluir
Primaria concluida
Nivel de instrucción Secundaria concluida
Técnico concluido
Universitario concluido
Directivos de gobierno y
empresas 14 o +
Profesionales científicos e
intelectuales
14 o +
Técnicos y profesionales de
nivel medio 14 o +
<14
Empleados de oficina y afines
14 o +
Trabajo de servicios, <14
vendedores y afines 14 o +
Trabajos agrícolas, forestales y <14
afines
14 o +
Artesanos y operarios de <14
oficios 14 o +
Operarios de maquinas e <14
Ocupación instalaciones
 Operarios de maquinas e
Ocupación instalaciones
14 o +
Peones y trabajadores no <14
calificados
14 o +
<14
Fuerzas armadas
14 o +
<14
Sin especificar u otros
14 o +
<14
Estudiante
14 o +
<14
Labores de casa
14 o +

Jubilado o renta dignidad

14 o +

Desempleado
14 o +
Sí
Contribuye a la economía familiar No
No corresponde
XI. MEDICINA TRADICIONAL(I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Siempre
Recurre a la Medicina A veces
Tradicional
Nunca
XII. NACIMIENTOS(I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Masculino
Sexo
Femenino
Dentro Establecimiento
Parto
Fuera Establecimiento
Personal establecimiento
Atendido por Partera
Familiar
Sí
¿Tiene certificación de nacimiento?
No
XIII. DEFUNCIONES (I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Enero
Febrero
Marzo
Abril
Mayo
Junio
Defunciones por mes
Julio
Agosto
Septiembre
Octubre
Noviembre
Diciembre
Institucional
Nro. de Defunciones
No institucional
Neonatal (< 28 días)
Con Certificado de Defunción
Médico
Otorgado por Autoridad
Otro
Sin Certificado de Defunción
XIII. DEFUNCIONES (I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
IRAs
EDAs
Embarazo/ Parto/ Puerperio
Malaria
TB
Corazón
Cáncer
Causa Probable Accidente de Tránsito
Accidente Laboral
Homicidio
Suicidio
Intoxicaciones
Mordedura de Ofidios
Desconoce /No Sabe
Otras
CARPETA FAMILIAR
_________

30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL

0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0
0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0
0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0
0 0
0 0
0 0
0 0
0
0 0
0
0 0
0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
 0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0
0 0
0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
 INSTRUMENTO DE SISTEMATIZACIÓN ANUAL DE LA CARPETA F
Año: ________________ SEDES__________________ Municipio: _____________________________________ Red de Salud: ______________________________________________
Ambito Geográfico: Urbano Rural Establecimiento: _______________________________________________________
Número de Carpetas Revisadas Comunidad/Localidad/Ciudad/Distrito:
Numeros de Seguimientos de Carpetas Familiares
CARPETAS Completas, Parciales, Bajas
I. DATOS GENERALES (F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
AYMARA
QUECHUA
Hablado CASTELLANO
GUARANI
OTROS
Idiomas
AYMARA
CASTELLANO
Materno QUECHUA
GUARANI
OTROS
<1
1-2
Kilometros
3-4
>4
< 30 minutos
Distancia y tiempo desde la vivienda 30 - 50 minutos
Tiempo a pie
hasta el establecimiento de salud 1 - 2 horas
>2 horas
< 30 minutos
30 - 50 minutos
Tiempo en movilidad
1 - 2 horas
>2 horas
Auxiliar en enfermeria
Cargo del Responsable de llenado Licenciado(a) en enfermeria
Médico(a)
IV. DETERMINANTES DE SALUD (F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
1. Vivienda individual 5
2. Departamento
A. Tipo de vivienda 3. Cuartos o habitaciones sueltas
4. Choza/Pahuichi/casa rústica
5. Ambiente no destinado para habitar
1. Propia 1
2. Anticrética
B. Tenencia de 3. Alquiler
Vivienda
4. Cuidador remunerado
5. Otros
1. Una o dos personas
2. Tres 10
C. No. de personas / 3. Cuatro
cuarto
4. cinco
5. Seis o más
IV. DETERMINANTES DE SALUD (F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
1. Agua por cañería
2. Pileta pública
D. Abastecimiento de agua 3. Pozo/Noria/Vertiente/ Cisterna 15
4. Acequia/río
5.Charcos/ Atajados/Curichi
1. Servicio higiénico en domicilio
2. Servicio higiénico público
E. Eliminación de excretas 3. Letrina
4. Pozo ciego
5. Aire libre 25
1. Recojo domiciliario
2. Basura enterrada 2
F. Manejo de Basura 3. Calle/campo abierto
4. Quemado
5. Río/Quebrada
1. Le permite ahorrar
2. Satisface necesidades
G. Ingreso Familiar 3. Satisface necesidades básicas 3
4. A veces no alcanza
5. Insuficiente
1. Cons. diario de cereales, tuberculos y derivados 5
2. Consumo diario de alimentos de origen animal 5
H. Consumo diário de alimentos 3. Consumo diario de frutas y verduras 5
4. Consumo diario de aceite 0
5. Consumo diario de sal yodada. 0
1. Universitaria
2. Técnico
I. Nivel de Instrucción de la madre 3. Secundaria
4. Básica 20
5. Sin Instrucción
Bajo 28 a 61 puntos
Rango de riesgo Medio 62 a 126 puntos 96
Alto 127 a 165 puntos
V. SALUD DE LOS INTEGRANTES DE LA FAMILIA (I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Nro DE INTEGRANTES DE LA FAMILIA
Menores de 5 años 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Mujeres embarazadas
Mayores de 60 años 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Habito de Fumar
Obesidad
Sedentarismo
Factores de Alimentación no adecuada
riesgo
Promiscuidad
Consumo excesivo de alcohol
Consumo de drogas
Problemas de salud
Higiene personal no adecuada
Riesgos laborales
Otros
Tuberculosis(pulmonar y extrapulmonar)
Lepra
Enfermedad de Chagas
Enfermedades VIH / SIDA
Transmisibles
Leishmaniasis
hepatitis
Otras
Neoplasmas malignos
Diabetes mellitus
Hipertensión arterial
Asma
Enfermedades No Cardiopatias(isquèmica, hipertensiva, reumàtica)
Transmisibles Enfermedades del Sistema locomotor(artrosis, artritis)
Enfermedad pulmonar obstructiva crónica
(EPOC)
Insuficiencia renal crónica
Desnutrición crónica
Otras
Intelectual
Fisica
Discapacidad
Sensorial
Multiple

MASCULINO
5-9
FEMENINO
MASCULINO
10-19
FEMENINO
Grupo de Riesgo I
MASCULINO
20-29
FEMENINO
MASCULINO
30-59
FEMENINO
 MASCULINO
<5
FEMENINO
MASCULINO
5-9
FEMENINO
MASCULINO
Problemas de salud 10-19
Grupo de Riesgo FEMENINO
II MASCULINO
20-29
FEMENINO
MASCULINO
30-59
FEMENINO
MASCULINO
60 o +
FEMENINO
MASCULINO
<5
FEMENINO
MASCULINO
5-9
FEMENINO
MASCULINO
10-19
Grupo de Riesgo FEMENINO
III MASCULINO
20-29
FEMENINO
MASCULINO
30-59
FEMENINO
MASCULINO
60 o +
FEMENINO
MASCULINO
<5
FEMENINO
MASCULINO
5-9
FEMENINO
MASCULINO
10-19
Grupo de Riesgo FEMENINO
IV MASCULINO
20-29
FEMENINO
MASCULINO
30-59
FEMENINO
MASCULINO
60 o +
FEMENINO
VI. COMPORTAMIENTO FAMILIAR(F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Violencia intrafamiliar
ACTIVO
Tabaquismo
PASIVO
Maltrato infantil
Consumo excesivo de alcohol
Consumo de drogas
VII. EVALUACIÓN DEL COMPORTAMIENTO FAMILIAR(F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Funcional
Disfuncional
VIII. RESULTADO DE LA EVALUACION DE LA SALUD FAMILIAR(F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Sin problema de salud
Dificultades con los determinantes de salud
Con problema de salud a predominio Dificultades con la salud de los integrantes de la familia
de:
Dificultades en el funcionamiento de la familia

IX. FORMA DE AYUDA FAMILIAR NECESARIA(F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29

Ayuda Educativa
Ayuda Terapéutica
Ayuda Comunitaria
X. ASPECTOS SOCIOCULTURALES (I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Sí
Residencia temporal
No
Sí
Lee No
No Corresponde
Sí 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Escribe No 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
No Corresponde 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Primaria sin concluir
Primaria concluida
Nivel de instrucción Secundaria concluida
Técnico concluido
Universitario concluido
Directivos de gobierno y
empresas 14 o +
Profesionales científicos e
intelectuales
14 o +
Técnicos y profesionales de
nivel medio 14 o +
<14
Empleados de oficina y afines
14 o +
Trabajo de servicios, <14
vendedores y afines 14 o +
Trabajos agrícolas, forestales y <14
afines
14 o +
Artesanos y operarios de <14
oficios 14 o +
Operarios de maquinas e <14
Ocupación instalaciones
 Operarios de maquinas e
Ocupación instalaciones
14 o +
Peones y trabajadores no <14
calificados
14 o +
<14
Fuerzas armadas
14 o +
<14
Sin especificar u otros
14 o +
<14
Estudiante
14 o +
<14
Labores de casa
14 o +

Jubilado o renta dignidad

14 o +

Desempleado
14 o +
Sí
Contribuye a la economía familiar No
No corresponde
XI. MEDICINA TRADICIONAL(I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Siempre
Recurre a la Medicina A veces
Tradicional
Nunca
XII. NACIMIENTOS(I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Masculino
Sexo
Femenino
Dentro Establecimiento
Parto
Fuera Establecimiento
Personal establecimiento
Atendido por Partera
Familiar
Sí
¿Tiene certificación de nacimiento?
No
XIII. DEFUNCIONES (I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Enero
Febrero
Marzo
Abril
Mayo
Junio
Defunciones por mes
Julio
Agosto
Septiembre
Octubre
Noviembre
Diciembre
Institucional
Nro. de Defunciones
No institucional
Neonatal (< 28 días)
Con Certificado de Defunción
Médico
Otorgado por Autoridad
Otro
Sin Certificado de Defunción
XIII. DEFUNCIONES (I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
IRAs
EDAs
Embarazo/ Parto/ Puerperio
Malaria
TB
Corazón
Cáncer
Causa Probable Accidente de Tránsito
Accidente Laboral
Homicidio
Suicidio
Intoxicaciones
Mordedura de Ofidios
Desconoce /No Sabe
Otras
CARPETA FAMILIAR
_________

30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL

0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
5 5
0 0
0 0
0 0
0 0
1 1
0 0
0 0
0 0
0 0
0 0
10 10
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
15 15
0 0
0 0
0 0
0 0
0 0
0 0
25 25
0 0
2 2
0 0
0 0
0 0
0 0
0 0
3 3
0 0
0 0
5 5
5 5
5 5
0 0
0 0
0 0
0 0
0 0
20 20
0 0
0 0
96 96
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2 0 0 0 0 2 2
0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0
0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0
0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
1 1 1 1 1 1 1 1 1 9 9
1 1 1 1 1 1 1 7 7
0 0
1 1 2 2
0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 1 1 1 1 0 0 7 7
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 2 2
0 0
1 1 1 1 1 5 5
1 1 2 2
1 1 1
0 0
0
0 0
0
0 0
0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
 0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0
0 0
0
0 0
1 1 1 3 3
1 1 1 1 1 1 6 6
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
1 1 1 3 3
1 1 1 1 1 1 6 6
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
 INSTRUMENTO DE SISTEMATIZACIÓN ANUAL DE LA CARPETA F
Año: ________________ SEDES__________________ Municipio: _____________________________________ Red de Salud: ______________________________________________
Ambito Geográfico: Urbano Rural Establecimiento: _______________________________________________________
Número de Carpetas Revisadas Comunidad/Localidad/Ciudad/Distrito:
Numeros de Seguimientos de Carpetas Familiares
CARPETAS Completas, Parciales, Bajas
I. DATOS GENERALES (F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
AYMARA
QUECHUA
Hablado CASTELLANO
GUARANI
OTROS
Idiomas
AYMARA
CASTELLANO
Materno QUECHUA
GUARANI
OTROS
<1
1-2
Kilometros
3-4
>4
< 30 minutos
Distancia y tiempo desde la vivienda 30 - 50 minutos
Tiempo a pie
hasta el establecimiento de salud 1 - 2 horas
>2 horas
< 30 minutos
30 - 50 minutos
Tiempo en movilidad
1 - 2 horas
>2 horas
Auxiliar en enfermeria
Cargo del Responsable de llenado Licenciado(a) en enfermeria
Médico(a)
IV. DETERMINANTES DE SALUD (F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
1. Vivienda individual
2. Departamento
A. Tipo de vivienda 3. Cuartos o habitaciones sueltas
4. Choza/Pahuichi/casa rústica
5. Ambiente no destinado para habitar
1. Propia
2. Anticrética
B. Tenencia de 3. Alquiler
Vivienda
4. Cuidador remunerado
5. Otros
1. Una o dos personas
2. Tres
C. No. de personas / 3. Cuatro
cuarto
4. cinco
5. Seis o más
IV. DETERMINANTES DE SALUD (F)
D. Abastecimiento de agua
E. Eliminación de excretas
F. Manejo de Basura
G. Ingreso Familiar
H. Consumo diário de alimentos
I. Nivel de Instrucción de la madre
Rango de riesgo
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
1. Agua por cañería
2. Pileta pública
3. Pozo/Noria/Vertiente/ Cisterna
4. Acequia/río
5.Charcos/ Atajados/Curichi
1. Servicio higiénico en domicilio
2. Servicio higiénico público
3. Letrina
4. Pozo ciego
5. Aire libre
1. Recojo domiciliario
2. Basura enterrada
3. Calle/campo abierto
4. Quemado
5. Río/Quebrada
1. Le permite ahorrar
2. Satisface necesidades
3. Satisface necesidades básicas
4. A veces no alcanza
5. Insuficiente
1. Cons. diario de cereales, tuberculos y derivados
2. Consumo diario de alimentos de origen animal
3. Consumo diario de frutas y verduras
4. Consumo diario de aceite
5. Consumo diario de sal yodada.
1. Universitaria
2. Técnico
3. Secundaria
4. Básica
5. Sin Instrucción
Bajo 28 a 61 puntos
Medio 62 a 126 puntos
Alto 127 a 165 puntos
V. SALUD DE LOS INTEGRANTES DE LA FAMILIA (I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Nro DE INTEGRANTES DE LA FAMILIA
Menores de 5 años 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Mujeres embarazadas
Mayores de 60 años 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Habito de Fumar
Obesidad
Sedentarismo
Factores de Alimentación no adecuada
riesgo
Promiscuidad
Consumo excesivo de alcohol
Consumo de drogas
Problemas de salud
Higiene personal no adecuada
Riesgos laborales
Otros
Tuberculosis(pulmonar y extrapulmonar)
Lepra
Enfermedad de Chagas
Enfermedades VIH / SIDA
Transmisibles
Leishmaniasis
hepatitis
Otras
Neoplasmas malignos
Diabetes mellitus
Hipertensión arterial
Asma
Enfermedades No Cardiopatias(isquèmica, hipertensiva, reumàtica)
Transmisibles Enfermedades del Sistema locomotor(artrosis, artritis)
Enfermedad pulmonar obstructiva crónica
(EPOC)
Insuficiencia renal crónica
Desnutrición crónica
Otras
Intelectual
Fisica
Discapacidad
Sensorial
Multiple

MASCULINO
5-9
FEMENINO
MASCULINO
10-19
FEMENINO
Grupo de Riesgo I
MASCULINO
20-29
FEMENINO
MASCULINO
30-59
FEMENINO
 MASCULINO
<5
FEMENINO
MASCULINO
5-9
FEMENINO
MASCULINO
Problemas de salud 10-19
Grupo de Riesgo FEMENINO
II MASCULINO
20-29
FEMENINO
MASCULINO
30-59
FEMENINO
MASCULINO
60 o +
FEMENINO
MASCULINO
<5
FEMENINO
MASCULINO
5-9
FEMENINO
MASCULINO
10-19
Grupo de Riesgo FEMENINO
III MASCULINO
20-29
FEMENINO
MASCULINO
30-59
FEMENINO
MASCULINO
60 o +
FEMENINO
MASCULINO
<5
FEMENINO
MASCULINO
5-9
FEMENINO
MASCULINO
10-19
Grupo de Riesgo FEMENINO
IV MASCULINO
20-29
FEMENINO
MASCULINO
30-59
FEMENINO
MASCULINO
60 o +
FEMENINO
VI. COMPORTAMIENTO FAMILIAR(F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Violencia intrafamiliar
ACTIVO
Tabaquismo
PASIVO
Maltrato infantil
Consumo excesivo de alcohol
Consumo de drogas
VII. EVALUACIÓN DEL COMPORTAMIENTO FAMILIAR(F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Funcional
Disfuncional
VIII. RESULTADO DE LA EVALUACION DE LA SALUD FAMILIAR(F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Sin problema de salud
Dificultades con los determinantes de salud
Con problema de salud a predominio Dificultades con la salud de los integrantes de la familia
de:
Dificultades en el funcionamiento de la familia

IX. FORMA DE AYUDA FAMILIAR NECESARIA(F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29

Ayuda Educativa
Ayuda Terapéutica
Ayuda Comunitaria
X. ASPECTOS SOCIOCULTURALES (I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Sí
Residencia temporal
No
Sí
Lee No
No Corresponde
Sí 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Escribe No 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
No Corresponde 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Primaria sin concluir
Primaria concluida
Nivel de instrucción Secundaria concluida
Técnico concluido
Universitario concluido
Directivos de gobierno y
empresas 14 o +
Profesionales científicos e
intelectuales
14 o +
Técnicos y profesionales de
nivel medio 14 o +
<14
Empleados de oficina y afines
14 o +
Trabajo de servicios, <14
vendedores y afines 14 o +
Trabajos agrícolas, forestales y <14
afines
14 o +
Artesanos y operarios de <14
oficios 14 o +
Operarios de maquinas e <14
Ocupación instalaciones
 Operarios de maquinas e
Ocupación instalaciones
14 o +
Peones y trabajadores no <14
calificados
14 o +
<14
Fuerzas armadas
14 o +
<14
Sin especificar u otros
14 o +
<14
Estudiante
14 o +
<14
Labores de casa
14 o +

Jubilado o renta dignidad

14 o +

Desempleado
14 o +
Sí
Contribuye a la economía familiar No
No corresponde
XI. MEDICINA TRADICIONAL(I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Siempre
Recurre a la Medicina A veces
Tradicional
Nunca
XII. NACIMIENTOS(I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Masculino
Sexo
Femenino
Dentro Establecimiento
Parto
Fuera Establecimiento
Personal establecimiento
Atendido por Partera
Familiar
Sí
¿Tiene certificación de nacimiento?
No
XIII. DEFUNCIONES (I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Enero
Febrero
Marzo
Abril
Mayo
Junio
Defunciones por mes
Julio
Agosto
Septiembre
Octubre
Noviembre
Diciembre
Institucional
Nro. de Defunciones
No institucional
Neonatal (< 28 días)
Con Certificado de Defunción
Médico
Otorgado por Autoridad
Otro
Sin Certificado de Defunción
XIII. DEFUNCIONES (I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
IRAs
EDAs
Embarazo/ Parto/ Puerperio
Malaria
TB
Corazón
Cáncer
Causa Probable Accidente de Tránsito
Accidente Laboral
Homicidio
Suicidio
Intoxicaciones
Mordedura de Ofidios
Desconoce /No Sabe
Otras
CARPETA FAMILIAR
_________

30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL

0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 5
0 0
0 0
0 0
0 0
0 1
0 0
0 0
0 0
0 0
0 0
0 10
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 15
0 0
0 0
0 0
0 0
0 0
0 0
0 25
0 0
0 2
0 0
0 0
0 0
0 0
0 0
0 3
0 0
0 0
0 5
0 5
0 5
0 0
0 0
0 0
0 0
0 0
0 20
0 0
0 0
0 96
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2
0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0
0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0
0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 9
0 7
0 0
0 2
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 7
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2
0 0
0 5
0 2
0 1
0 0
0
0 0
0
0 0
0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
 0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0
0 0
0
0 0
0 3
0 6
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 3
0 6
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
 INSTRUMENTO DE SISTEMATIZACIÓN ANUAL DE LA CARPETA F
Año: ________________ SEDES__________________ Municipio: _____________________________________ Red de Salud: ______________________________________________
Ambito Geográfico: Urbano Rural Establecimiento: _______________________________________________________
Número de Carpetas Revisadas Comunidad/Localidad/Ciudad/Distrito:
Numeros de Seguimientos de Carpetas Familiares
CARPETAS Completas, Parciales, Bajas
I. DATOS GENERALES (F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
AYMARA
QUECHUA
Hablado CASTELLANO
GUARANI
OTROS
Idiomas
AYMARA
CASTELLANO
Materno QUECHUA
GUARANI
OTROS
<1
1-2
Kilometros
3-4
>4
< 30 minutos
Distancia y tiempo desde la vivienda 30 - 50 minutos
Tiempo a pie
hasta el establecimiento de salud 1 - 2 horas
>2 horas
< 30 minutos
30 - 50 minutos
Tiempo en movilidad
1 - 2 horas
>2 horas
Auxiliar en enfermeria
Cargo del Responsable de llenado Licenciado(a) en enfermeria
Médico(a)
IV. DETERMINANTES DE SALUD (F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
1. Vivienda individual
2. Departamento
A. Tipo de vivienda 3. Cuartos o habitaciones sueltas
4. Choza/Pahuichi/casa rústica
5. Ambiente no destinado para habitar
1. Propia
2. Anticrética
B. Tenencia de 3. Alquiler
Vivienda
4. Cuidador remunerado
5. Otros
1. Una o dos personas
2. Tres
C. No. de personas / 3. Cuatro
cuarto
4. cinco
5. Seis o más
IV. DETERMINANTES DE SALUD (F)
D. Abastecimiento de agua
E. Eliminación de excretas
F. Manejo de Basura
G. Ingreso Familiar
H. Consumo diário de alimentos
I. Nivel de Instrucción de la madre
Rango de riesgo
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
1. Agua por cañería
2. Pileta pública
3. Pozo/Noria/Vertiente/ Cisterna
4. Acequia/río
5.Charcos/ Atajados/Curichi
1. Servicio higiénico en domicilio
2. Servicio higiénico público
3. Letrina
4. Pozo ciego
5. Aire libre
1. Recojo domiciliario
2. Basura enterrada
3. Calle/campo abierto
4. Quemado
5. Río/Quebrada
1. Le permite ahorrar
2. Satisface necesidades
3. Satisface necesidades básicas
4. A veces no alcanza
5. Insuficiente
1. Cons. diario de cereales, tuberculos y derivados
2. Consumo diario de alimentos de origen animal
3. Consumo diario de frutas y verduras
4. Consumo diario de aceite
5. Consumo diario de sal yodada.
1. Universitaria
2. Técnico
3. Secundaria
4. Básica
5. Sin Instrucción
Bajo 28 a 61 puntos
Medio 62 a 126 puntos
Alto 127 a 165 puntos
V. SALUD DE LOS INTEGRANTES DE LA FAMILIA (I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Nro DE INTEGRANTES DE LA FAMILIA
Menores de 5 años 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Mujeres embarazadas
Mayores de 60 años 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Habito de Fumar
Obesidad
Sedentarismo
Factores de Alimentación no adecuada
riesgo
Promiscuidad
Consumo excesivo de alcohol
Consumo de drogas
Problemas de salud
Higiene personal no adecuada
Riesgos laborales
Otros
Tuberculosis(pulmonar y extrapulmonar)
Lepra
Enfermedad de Chagas
Enfermedades VIH / SIDA
Transmisibles
Leishmaniasis
hepatitis
Otras
Neoplasmas malignos
Diabetes mellitus
Hipertensión arterial
Asma
Enfermedades No Cardiopatias(isquèmica, hipertensiva, reumàtica)
Transmisibles Enfermedades del Sistema locomotor(artrosis, artritis)
Enfermedad pulmonar obstructiva crónica
(EPOC)
Insuficiencia renal crónica
Desnutrición crónica
Otras
Intelectual
Fisica
Discapacidad
Sensorial
Multiple

MASCULINO
5-9
FEMENINO
MASCULINO
10-19
FEMENINO
Grupo de Riesgo I
MASCULINO
20-29
FEMENINO
MASCULINO
30-59
FEMENINO
 MASCULINO
<5
FEMENINO
MASCULINO
5-9
FEMENINO
MASCULINO
Problemas de salud 10-19
Grupo de Riesgo FEMENINO
II MASCULINO
20-29
FEMENINO
MASCULINO
30-59
FEMENINO
MASCULINO
60 o +
FEMENINO
MASCULINO
<5
FEMENINO
MASCULINO
5-9
FEMENINO
MASCULINO
10-19
Grupo de Riesgo FEMENINO
III MASCULINO
20-29
FEMENINO
MASCULINO
30-59
FEMENINO
MASCULINO
60 o +
FEMENINO
MASCULINO
<5
FEMENINO
MASCULINO
5-9
FEMENINO
MASCULINO
10-19
Grupo de Riesgo FEMENINO
IV MASCULINO
20-29
FEMENINO
MASCULINO
30-59
FEMENINO
MASCULINO
60 o +
FEMENINO
VI. COMPORTAMIENTO FAMILIAR(F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Violencia intrafamiliar
ACTIVO
Tabaquismo
PASIVO
Maltrato infantil
Consumo excesivo de alcohol
Consumo de drogas
VII. EVALUACIÓN DEL COMPORTAMIENTO FAMILIAR(F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Funcional
Disfuncional
VIII. RESULTADO DE LA EVALUACION DE LA SALUD FAMILIAR(F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Sin problema de salud
Dificultades con los determinantes de salud
Con problema de salud a predominio Dificultades con la salud de los integrantes de la familia
de:
Dificultades en el funcionamiento de la familia

IX. FORMA DE AYUDA FAMILIAR NECESARIA(F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29

Ayuda Educativa
Ayuda Terapéutica
Ayuda Comunitaria
X. ASPECTOS SOCIOCULTURALES (I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Sí
Residencia temporal
No
Sí
Lee No
No Corresponde
Sí 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Escribe No 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
No Corresponde 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Primaria sin concluir
Primaria concluida
Nivel de instrucción Secundaria concluida
Técnico concluido
Universitario concluido
Directivos de gobierno y
empresas 14 o +
Profesionales científicos e
intelectuales
14 o +
Técnicos y profesionales de
nivel medio 14 o +
<14
Empleados de oficina y afines
14 o +
Trabajo de servicios, <14
vendedores y afines 14 o +
Trabajos agrícolas, forestales y <14
afines
14 o +
Artesanos y operarios de <14
oficios 14 o +
Operarios de maquinas e <14
Ocupación instalaciones
 Operarios de maquinas e
Ocupación instalaciones
14 o +
Peones y trabajadores no <14
calificados
14 o +
<14
Fuerzas armadas
14 o +
<14
Sin especificar u otros
14 o +
<14
Estudiante
14 o +
<14
Labores de casa
14 o +

Jubilado o renta dignidad

14 o +

Desempleado
14 o +
Sí
Contribuye a la economía familiar No
No corresponde
XI. MEDICINA TRADICIONAL(I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Siempre
Recurre a la Medicina A veces
Tradicional
Nunca
XII. NACIMIENTOS(I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Masculino
Sexo
Femenino
Dentro Establecimiento
Parto
Fuera Establecimiento
Personal establecimiento
Atendido por Partera
Familiar
Sí
¿Tiene certificación de nacimiento?
No
XIII. DEFUNCIONES (I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Enero
Febrero
Marzo
Abril
Mayo
Junio
Defunciones por mes
Julio
Agosto
Septiembre
Octubre
Noviembre
Diciembre
Institucional
Nro. de Defunciones
No institucional
Neonatal (< 28 días)
Con Certificado de Defunción
Médico
Otorgado por Autoridad
Otro
Sin Certificado de Defunción
XIII. DEFUNCIONES (I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
IRAs
EDAs
Embarazo/ Parto/ Puerperio
Malaria
TB
Corazón
Cáncer
Causa Probable Accidente de Tránsito
Accidente Laboral
Homicidio
Suicidio
Intoxicaciones
Mordedura de Ofidios
Desconoce /No Sabe
Otras
CARPETA FAMILIAR
_________

30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL

0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 5
0 0
0 0
0 0
0 0
0 1
0 0
0 0
0 0
0 0
0 0
0 10
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 15
0 0
0 0
0 0
0 0
0 0
0 0
0 25
0 0
0 2
0 0
0 0
0 0
0 0
0 0
0 3
0 0
0 0
0 5
0 5
0 5
0 0
0 0
0 0
0 0
0 0
0 20
0 0
0 0
0 96
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2
0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0
0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0
0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 9
0 7
0 0
0 2
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 7
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2
0 0
0 5
0 2
0 1
0 0
0
0 0
0
0 0
0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
 0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0
0 0
0
0 0
0 3
0 6
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 3
0 6
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
 INSTRUMENTO DE SISTEMATIZACIÓN ANUAL DE LA CARPETA F
Año: ________________ SEDES__________________ Municipio: _____________________________________ Red de Salud: ______________________________________________
Ambito Geográfico: Urbano Rural Establecimiento: _______________________________________________________
Número de Carpetas Revisadas Comunidad/Localidad/Ciudad/Distrito:
Numeros de Seguimientos de Carpetas Familiares
CARPETAS Completas, Parciales, Bajas
I. DATOS GENERALES (F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
AYMARA
QUECHUA
Hablado CASTELLANO
GUARANI
OTROS
Idiomas
AYMARA
CASTELLANO
Materno QUECHUA
GUARANI
OTROS
<1
1-2
Kilometros
3-4
>4
< 30 minutos
Distancia y tiempo desde la vivienda 30 - 50 minutos
Tiempo a pie
hasta el establecimiento de salud 1 - 2 horas
>2 horas
< 30 minutos
30 - 50 minutos
Tiempo en movilidad
1 - 2 horas
>2 horas
Auxiliar en enfermeria
Cargo del Responsable de llenado Licenciado(a) en enfermeria
Médico(a)
IV. DETERMINANTES DE SALUD (F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
1. Vivienda individual
2. Departamento
A. Tipo de vivienda 3. Cuartos o habitaciones sueltas
4. Choza/Pahuichi/casa rústica
5. Ambiente no destinado para habitar
1. Propia
2. Anticrética
B. Tenencia de 3. Alquiler
Vivienda
4. Cuidador remunerado
5. Otros
1. Una o dos personas
2. Tres
C. No. de personas / 3. Cuatro
cuarto
4. cinco
5. Seis o más
IV. DETERMINANTES DE SALUD (F)
D. Abastecimiento de agua
E. Eliminación de excretas
F. Manejo de Basura
G. Ingreso Familiar
H. Consumo diário de alimentos
I. Nivel de Instrucción de la madre
Rango de riesgo
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
1. Agua por cañería
2. Pileta pública
3. Pozo/Noria/Vertiente/ Cisterna
4. Acequia/río
5.Charcos/ Atajados/Curichi
1. Servicio higiénico en domicilio
2. Servicio higiénico público
3. Letrina
4. Pozo ciego
5. Aire libre
1. Recojo domiciliario
2. Basura enterrada
3. Calle/campo abierto
4. Quemado
5. Río/Quebrada
1. Le permite ahorrar
2. Satisface necesidades
3. Satisface necesidades básicas
4. A veces no alcanza
5. Insuficiente
1. Cons. diario de cereales, tuberculos y derivados
2. Consumo diario de alimentos de origen animal
3. Consumo diario de frutas y verduras
4. Consumo diario de aceite
5. Consumo diario de sal yodada.
1. Universitaria
2. Técnico
3. Secundaria
4. Básica
5. Sin Instrucción
Bajo 28 a 61 puntos
Medio 62 a 126 puntos
Alto 127 a 165 puntos
V. SALUD DE LOS INTEGRANTES DE LA FAMILIA (I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Nro DE INTEGRANTES DE LA FAMILIA
Menores de 5 años 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Mujeres embarazadas
Mayores de 60 años 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Habito de Fumar
Obesidad
Sedentarismo
Factores de Alimentación no adecuada
riesgo
Promiscuidad
Consumo excesivo de alcohol
Consumo de drogas
Problemas de salud
Higiene personal no adecuada
Riesgos laborales
Otros
Tuberculosis(pulmonar y extrapulmonar)
Lepra
Enfermedad de Chagas
Enfermedades VIH / SIDA
Transmisibles
Leishmaniasis
hepatitis
Otras
Neoplasmas malignos
Diabetes mellitus
Hipertensión arterial
Asma
Enfermedades No Cardiopatias(isquèmica, hipertensiva, reumàtica)
Transmisibles Enfermedades del Sistema locomotor(artrosis, artritis)
Enfermedad pulmonar obstructiva crónica
(EPOC)
Insuficiencia renal crónica
Desnutrición crónica
Otras
Intelectual
Fisica
Discapacidad
Sensorial
Multiple

MASCULINO
5-9
FEMENINO
MASCULINO
10-19
FEMENINO
Grupo de Riesgo I
MASCULINO
20-29
FEMENINO
MASCULINO
30-59
FEMENINO
 MASCULINO
<5
FEMENINO
MASCULINO
5-9
FEMENINO
MASCULINO
Problemas de salud 10-19
Grupo de Riesgo FEMENINO
II MASCULINO
20-29
FEMENINO
MASCULINO
30-59
FEMENINO
MASCULINO
60 o +
FEMENINO
MASCULINO
<5
FEMENINO
MASCULINO
5-9
FEMENINO
MASCULINO
10-19
Grupo de Riesgo FEMENINO
III MASCULINO
20-29
FEMENINO
MASCULINO
30-59
FEMENINO
MASCULINO
60 o +
FEMENINO
MASCULINO
<5
FEMENINO
MASCULINO
5-9
FEMENINO
MASCULINO
10-19
Grupo de Riesgo FEMENINO
IV MASCULINO
20-29
FEMENINO
MASCULINO
30-59
FEMENINO
MASCULINO
60 o +
FEMENINO
VI. COMPORTAMIENTO FAMILIAR(F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Violencia intrafamiliar
ACTIVO
Tabaquismo
PASIVO
Maltrato infantil
Consumo excesivo de alcohol
Consumo de drogas
VII. EVALUACIÓN DEL COMPORTAMIENTO FAMILIAR(F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Funcional
Disfuncional
VIII. RESULTADO DE LA EVALUACION DE LA SALUD FAMILIAR(F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Sin problema de salud
Dificultades con los determinantes de salud
Con problema de salud a predominio Dificultades con la salud de los integrantes de la familia
de:
Dificultades en el funcionamiento de la familia

IX. FORMA DE AYUDA FAMILIAR NECESARIA(F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29

Ayuda Educativa
Ayuda Terapéutica
Ayuda Comunitaria
X. ASPECTOS SOCIOCULTURALES (I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Sí
Residencia temporal
No
Sí
Lee No
No Corresponde
Sí 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Escribe No 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
No Corresponde 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Primaria sin concluir
Primaria concluida
Nivel de instrucción Secundaria concluida
Técnico concluido
Universitario concluido
Directivos de gobierno y
empresas 14 o +
Profesionales científicos e
intelectuales
14 o +
Técnicos y profesionales de
nivel medio 14 o +
<14
Empleados de oficina y afines
14 o +
Trabajo de servicios, <14
vendedores y afines 14 o +
Trabajos agrícolas, forestales y <14
afines
14 o +
Artesanos y operarios de <14
oficios 14 o +
Operarios de maquinas e <14
Ocupación instalaciones
 Operarios de maquinas e
Ocupación instalaciones
14 o +
Peones y trabajadores no <14
calificados
14 o +
<14
Fuerzas armadas
14 o +
<14
Sin especificar u otros
14 o +
<14
Estudiante
14 o +
<14
Labores de casa
14 o +

Jubilado o renta dignidad

14 o +

Desempleado
14 o +
Sí
Contribuye a la economía familiar No
No corresponde
XI. MEDICINA TRADICIONAL(I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Siempre
Recurre a la Medicina A veces
Tradicional
Nunca
XII. NACIMIENTOS(I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Masculino
Sexo
Femenino
Dentro Establecimiento
Parto
Fuera Establecimiento
Personal establecimiento
Atendido por Partera
Familiar
Sí
¿Tiene certificación de nacimiento?
No
XIII. DEFUNCIONES (I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Enero
Febrero
Marzo
Abril
Mayo
Junio
Defunciones por mes
Julio
Agosto
Septiembre
Octubre
Noviembre
Diciembre
Institucional
Nro. de Defunciones
No institucional
Neonatal (< 28 días)
Con Certificado de Defunción
Médico
Otorgado por Autoridad
Otro
Sin Certificado de Defunción
XIII. DEFUNCIONES (I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
IRAs
EDAs
Embarazo/ Parto/ Puerperio
Malaria
TB
Corazón
Cáncer
Causa Probable Accidente de Tránsito
Accidente Laboral
Homicidio
Suicidio
Intoxicaciones
Mordedura de Ofidios
Desconoce /No Sabe
Otras
CARPETA FAMILIAR
_________

30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL

0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 5
0 0
0 0
0 0
0 0
0 1
0 0
0 0
0 0
0 0
0 0
0 10
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 15
0 0
0 0
0 0
0 0
0 0
0 0
0 25
0 0
0 2
0 0
0 0
0 0
0 0
0 0
0 3
0 0
0 0
0 5
0 5
0 5
0 0
0 0
0 0
0 0
0 0
0 20
0 0
0 0
0 96
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2
0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0
0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0
0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 9
0 7
0 0
0 2
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 7
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2
0 0
0 5
0 2
0 1
0 0
0
0 0
0
0 0
0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
 0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0
0 0
0
0 0
0 3
0 6
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 3
0 6
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
 INSTRUMENTO DE SISTEMATIZACIÓN ANUAL DE LA CARPETA F
Año: ________________ SEDES__________________ Municipio: _____________________________________ Red de Salud: ______________________________________________
Ambito Geográfico: Urbano Rural Establecimiento: _______________________________________________________
Número de Carpetas Revisadas Comunidad/Localidad/Ciudad/Distrito:
Numeros de Seguimientos de Carpetas Familiares
CARPETAS Completas, Parciales, Bajas
I. DATOS GENERALES (F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
AYMARA
QUECHUA
Hablado CASTELLANO
GUARANI
OTROS
Idiomas
AYMARA
CASTELLANO
Materno QUECHUA
GUARANI
OTROS
<1
1-2
Kilometros
3-4
>4
< 30 minutos
Distancia y tiempo desde la vivienda 30 - 50 minutos
Tiempo a pie
hasta el establecimiento de salud 1 - 2 horas
>2 horas
< 30 minutos
30 - 50 minutos
Tiempo en movilidad
1 - 2 horas
>2 horas
Auxiliar en enfermeria
Cargo del Responsable de llenado Licenciado(a) en enfermeria
Médico(a)
IV. DETERMINANTES DE SALUD (F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
1. Vivienda individual
2. Departamento
A. Tipo de vivienda 3. Cuartos o habitaciones sueltas
4. Choza/Pahuichi/casa rústica
5. Ambiente no destinado para habitar
1. Propia
2. Anticrética
B. Tenencia de 3. Alquiler
Vivienda
4. Cuidador remunerado
5. Otros
1. Una o dos personas
2. Tres
C. No. de personas / 3. Cuatro
cuarto
4. cinco
5. Seis o más
IV. DETERMINANTES DE SALUD (F)
D. Abastecimiento de agua
E. Eliminación de excretas
F. Manejo de Basura
G. Ingreso Familiar
H. Consumo diário de alimentos
I. Nivel de Instrucción de la madre
Rango de riesgo
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
1. Agua por cañería
2. Pileta pública
3. Pozo/Noria/Vertiente/ Cisterna
4. Acequia/río
5.Charcos/ Atajados/Curichi
1. Servicio higiénico en domicilio
2. Servicio higiénico público
3. Letrina
4. Pozo ciego
5. Aire libre
1. Recojo domiciliario
2. Basura enterrada
3. Calle/campo abierto
4. Quemado
5. Río/Quebrada
1. Le permite ahorrar
2. Satisface necesidades
3. Satisface necesidades básicas
4. A veces no alcanza
5. Insuficiente
1. Cons. diario de cereales, tuberculos y derivados
2. Consumo diario de alimentos de origen animal
3. Consumo diario de frutas y verduras
4. Consumo diario de aceite
5. Consumo diario de sal yodada.
1. Universitaria
2. Técnico
3. Secundaria
4. Básica
5. Sin Instrucción
Bajo 28 a 61 puntos
Medio 62 a 126 puntos
Alto 127 a 165 puntos
V. SALUD DE LOS INTEGRANTES DE LA FAMILIA (I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Nro DE INTEGRANTES DE LA FAMILIA
Menores de 5 años 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Mujeres embarazadas
Mayores de 60 años 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Habito de Fumar
Obesidad
Sedentarismo
Factores de Alimentación no adecuada
riesgo
Promiscuidad
Consumo excesivo de alcohol
Consumo de drogas
Problemas de salud
Higiene personal no adecuada
Riesgos laborales
Otros
Tuberculosis(pulmonar y extrapulmonar)
Lepra
Enfermedad de Chagas
Enfermedades VIH / SIDA
Transmisibles
Leishmaniasis
hepatitis
Otras
Neoplasmas malignos
Diabetes mellitus
Hipertensión arterial
Asma
Enfermedades No Cardiopatias(isquèmica, hipertensiva, reumàtica)
Transmisibles Enfermedades del Sistema locomotor(artrosis, artritis)
Enfermedad pulmonar obstructiva crónica
(EPOC)
Insuficiencia renal crónica
Desnutrición crónica
Otras
Intelectual
Fisica
Discapacidad
Sensorial
Multiple

MASCULINO
5-9
FEMENINO
MASCULINO
10-19
FEMENINO
Grupo de Riesgo I
MASCULINO
20-29
FEMENINO
MASCULINO
30-59
FEMENINO
 MASCULINO
<5
FEMENINO
MASCULINO
5-9
FEMENINO
MASCULINO
Problemas de salud 10-19
Grupo de Riesgo FEMENINO
II MASCULINO
20-29
FEMENINO
MASCULINO
30-59
FEMENINO
MASCULINO
60 o +
FEMENINO
MASCULINO
<5
FEMENINO
MASCULINO
5-9
FEMENINO
MASCULINO
10-19
Grupo de Riesgo FEMENINO
III MASCULINO
20-29
FEMENINO
MASCULINO
30-59
FEMENINO
MASCULINO
60 o +
FEMENINO
MASCULINO
<5
FEMENINO
MASCULINO
5-9
FEMENINO
MASCULINO
10-19
Grupo de Riesgo FEMENINO
IV MASCULINO
20-29
FEMENINO
MASCULINO
30-59
FEMENINO
MASCULINO
60 o +
FEMENINO
VI. COMPORTAMIENTO FAMILIAR(F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Violencia intrafamiliar
ACTIVO
Tabaquismo
PASIVO
Maltrato infantil
Consumo excesivo de alcohol
Consumo de drogas
VII. EVALUACIÓN DEL COMPORTAMIENTO FAMILIAR(F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Funcional
Disfuncional
VIII. RESULTADO DE LA EVALUACION DE LA SALUD FAMILIAR(F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Sin problema de salud
Dificultades con los determinantes de salud
Con problema de salud a predominio Dificultades con la salud de los integrantes de la familia
de:
Dificultades en el funcionamiento de la familia

IX. FORMA DE AYUDA FAMILIAR NECESARIA(F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29

Ayuda Educativa
Ayuda Terapéutica
Ayuda Comunitaria
X. ASPECTOS SOCIOCULTURALES (I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Sí
Residencia temporal
No
Sí
Lee No
No Corresponde
Sí 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Escribe No 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
No Corresponde 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Primaria sin concluir
Primaria concluida
Nivel de instrucción Secundaria concluida
Técnico concluido
Universitario concluido
Directivos de gobierno y
empresas 14 o +
Profesionales científicos e
intelectuales
14 o +
Técnicos y profesionales de
nivel medio 14 o +
<14
Empleados de oficina y afines
14 o +
Trabajo de servicios, <14
vendedores y afines 14 o +
Trabajos agrícolas, forestales y <14
afines
14 o +
Artesanos y operarios de <14
oficios 14 o +
Operarios de maquinas e <14
Ocupación instalaciones
 Operarios de maquinas e
Ocupación instalaciones
14 o +
Peones y trabajadores no <14
calificados
14 o +
<14
Fuerzas armadas
14 o +
<14
Sin especificar u otros
14 o +
<14
Estudiante
14 o +
<14
Labores de casa
14 o +

Jubilado o renta dignidad

14 o +

Desempleado
14 o +
Sí
Contribuye a la economía familiar No
No corresponde
XI. MEDICINA TRADICIONAL(I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Siempre
Recurre a la Medicina A veces
Tradicional
Nunca
XII. NACIMIENTOS(I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Masculino
Sexo
Femenino
Dentro Establecimiento
Parto
Fuera Establecimiento
Personal establecimiento
Atendido por Partera
Familiar
Sí
¿Tiene certificación de nacimiento?
No
XIII. DEFUNCIONES (I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Enero
Febrero
Marzo
Abril
Mayo
Junio
Defunciones por mes
Julio
Agosto
Septiembre
Octubre
Noviembre
Diciembre
Institucional
Nro. de Defunciones
No institucional
Neonatal (< 28 días)
Con Certificado de Defunción
Médico
Otorgado por Autoridad
Otro
Sin Certificado de Defunción
XIII. DEFUNCIONES (I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
IRAs
EDAs
Embarazo/ Parto/ Puerperio
Malaria
TB
Corazón
Cáncer
Causa Probable Accidente de Tránsito
Accidente Laboral
Homicidio
Suicidio
Intoxicaciones
Mordedura de Ofidios
Desconoce /No Sabe
Otras
CARPETA FAMILIAR
_________

30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL

0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 5
0 0
0 0
0 0
0 0
0 1
0 0
0 0
0 0
0 0
0 0
0 10
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 15
0 0
0 0
0 0
0 0
0 0
0 0
0 25
0 0
0 2
0 0
0 0
0 0
0 0
0 0
0 3
0 0
0 0
0 5
0 5
0 5
0 0
0 0
0 0
0 0
0 0
0 20
0 0
0 0
0 96
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2
0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0
0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0
0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 9
0 7
0 0
0 2
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 7
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2
0 0
0 5
0 2
0 1
0 0
0
0 0
0
0 0
0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
 0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0
0 0
0
0 0
0 3
0 6
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 3
0 6
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
 INSTRUMENTO DE SISTEMATIZACIÓN ANUAL DE LA CARPETA F
Año: ________________ SEDES__________________ Municipio: _____________________________________ Red de Salud: ______________________________________________
Ambito Geográfico: Urbano Rural Establecimiento: _______________________________________________________
Número de Carpetas Revisadas Comunidad/Localidad/Ciudad/Distrito:
Numeros de Seguimientos de Carpetas Familiares
CARPETAS Completas, Parciales, Bajas
I. DATOS GENERALES (F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
AYMARA
QUECHUA
Hablado CASTELLANO
GUARANI
OTROS
Idiomas
AYMARA
CASTELLANO
Materno QUECHUA
GUARANI
OTROS
<1
1-2
Kilometros
3-4
>4
< 30 minutos
Distancia y tiempo desde la vivienda 30 - 50 minutos
Tiempo a pie
hasta el establecimiento de salud 1 - 2 horas
>2 horas
< 30 minutos
30 - 50 minutos
Tiempo en movilidad
1 - 2 horas
>2 horas
Auxiliar en enfermeria
Cargo del Responsable de llenado Licenciado(a) en enfermeria
Médico(a)
IV. DETERMINANTES DE SALUD (F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
1. Vivienda individual
2. Departamento
A. Tipo de vivienda 3. Cuartos o habitaciones sueltas
4. Choza/Pahuichi/casa rústica
5. Ambiente no destinado para habitar
1. Propia
2. Anticrética
B. Tenencia de 3. Alquiler
Vivienda
4. Cuidador remunerado
5. Otros
1. Una o dos personas
2. Tres
C. No. de personas / 3. Cuatro
cuarto
4. cinco
5. Seis o más
IV. DETERMINANTES DE SALUD (F)
D. Abastecimiento de agua
E. Eliminación de excretas
F. Manejo de Basura
G. Ingreso Familiar
H. Consumo diário de alimentos
I. Nivel de Instrucción de la madre
Rango de riesgo
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
1. Agua por cañería
2. Pileta pública
3. Pozo/Noria/Vertiente/ Cisterna
4. Acequia/río
5.Charcos/ Atajados/Curichi
1. Servicio higiénico en domicilio
2. Servicio higiénico público
3. Letrina
4. Pozo ciego
5. Aire libre
1. Recojo domiciliario
2. Basura enterrada
3. Calle/campo abierto
4. Quemado
5. Río/Quebrada
1. Le permite ahorrar
2. Satisface necesidades
3. Satisface necesidades básicas
4. A veces no alcanza
5. Insuficiente
1. Cons. diario de cereales, tuberculos y derivados
2. Consumo diario de alimentos de origen animal
3. Consumo diario de frutas y verduras
4. Consumo diario de aceite
5. Consumo diario de sal yodada.
1. Universitaria
2. Técnico
3. Secundaria
4. Básica
5. Sin Instrucción
Bajo 28 a 61 puntos
Medio 62 a 126 puntos
Alto 127 a 165 puntos
V. SALUD DE LOS INTEGRANTES DE LA FAMILIA (I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Nro DE INTEGRANTES DE LA FAMILIA
Menores de 5 años 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Mujeres embarazadas
Mayores de 60 años 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Habito de Fumar
Obesidad
Sedentarismo
Factores de Alimentación no adecuada
riesgo
Promiscuidad
Consumo excesivo de alcohol
Consumo de drogas
Problemas de salud
Higiene personal no adecuada
Riesgos laborales
Otros
Tuberculosis(pulmonar y extrapulmonar)
Lepra
Enfermedad de Chagas
Enfermedades VIH / SIDA
Transmisibles
Leishmaniasis
hepatitis
Otras
Neoplasmas malignos
Diabetes mellitus
Hipertensión arterial
Asma
Enfermedades No Cardiopatias(isquèmica, hipertensiva, reumàtica)
Transmisibles Enfermedades del Sistema locomotor(artrosis, artritis)
Enfermedad pulmonar obstructiva crónica
(EPOC)
Insuficiencia renal crónica
Desnutrición crónica
Otras
Intelectual
Fisica
Discapacidad
Sensorial
Multiple

MASCULINO
5-9
FEMENINO
MASCULINO
10-19
FEMENINO
Grupo de Riesgo I
MASCULINO
20-29
FEMENINO
MASCULINO
30-59
FEMENINO
 MASCULINO
<5
FEMENINO
MASCULINO
5-9
FEMENINO
MASCULINO
Problemas de salud 10-19
Grupo de Riesgo FEMENINO
II MASCULINO
20-29
FEMENINO
MASCULINO
30-59
FEMENINO
MASCULINO
60 o +
FEMENINO
MASCULINO
<5
FEMENINO
MASCULINO
5-9
FEMENINO
MASCULINO
10-19
Grupo de Riesgo FEMENINO
III MASCULINO
20-29
FEMENINO
MASCULINO
30-59
FEMENINO
MASCULINO
60 o +
FEMENINO
MASCULINO
<5
FEMENINO
MASCULINO
5-9
FEMENINO
MASCULINO
10-19
Grupo de Riesgo FEMENINO
IV MASCULINO
20-29
FEMENINO
MASCULINO
30-59
FEMENINO
MASCULINO
60 o +
FEMENINO
VI. COMPORTAMIENTO FAMILIAR(F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Violencia intrafamiliar
ACTIVO
Tabaquismo
PASIVO
Maltrato infantil
Consumo excesivo de alcohol
Consumo de drogas
VII. EVALUACIÓN DEL COMPORTAMIENTO FAMILIAR(F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Funcional
Disfuncional
VIII. RESULTADO DE LA EVALUACION DE LA SALUD FAMILIAR(F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Sin problema de salud
Dificultades con los determinantes de salud
Con problema de salud a predominio Dificultades con la salud de los integrantes de la familia
de:
Dificultades en el funcionamiento de la familia

IX. FORMA DE AYUDA FAMILIAR NECESARIA(F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29

Ayuda Educativa
Ayuda Terapéutica
Ayuda Comunitaria
X. ASPECTOS SOCIOCULTURALES (I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Sí
Residencia temporal
No
Sí
Lee No
No Corresponde
Sí 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Escribe No 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
No Corresponde 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Primaria sin concluir
Primaria concluida
Nivel de instrucción Secundaria concluida
Técnico concluido
Universitario concluido
Directivos de gobierno y
empresas 14 o +
Profesionales científicos e
intelectuales
14 o +
Técnicos y profesionales de
nivel medio 14 o +
<14
Empleados de oficina y afines
14 o +
Trabajo de servicios, <14
vendedores y afines 14 o +
Trabajos agrícolas, forestales y <14
afines
14 o +
Artesanos y operarios de <14
oficios 14 o +
Operarios de maquinas e <14
Ocupación instalaciones
 Operarios de maquinas e
Ocupación instalaciones
14 o +
Peones y trabajadores no <14
calificados
14 o +
<14
Fuerzas armadas
14 o +
<14
Sin especificar u otros
14 o +
<14
Estudiante
14 o +
<14
Labores de casa
14 o +

Jubilado o renta dignidad

14 o +

Desempleado
14 o +
Sí
Contribuye a la economía familiar No
No corresponde
XI. MEDICINA TRADICIONAL(I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Siempre
Recurre a la Medicina A veces
Tradicional
Nunca
XII. NACIMIENTOS(I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Masculino
Sexo
Femenino
Dentro Establecimiento
Parto
Fuera Establecimiento
Personal establecimiento
Atendido por Partera
Familiar
Sí
¿Tiene certificación de nacimiento?
No
XIII. DEFUNCIONES (I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Enero
Febrero
Marzo
Abril
Mayo
Junio
Defunciones por mes
Julio
Agosto
Septiembre
Octubre
Noviembre
Diciembre
Institucional
Nro. de Defunciones
No institucional
Neonatal (< 28 días)
Con Certificado de Defunción
Médico
Otorgado por Autoridad
Otro
Sin Certificado de Defunción
XIII. DEFUNCIONES (I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
IRAs
EDAs
Embarazo/ Parto/ Puerperio
Malaria
TB
Corazón
Cáncer
Causa Probable Accidente de Tránsito
Accidente Laboral
Homicidio
Suicidio
Intoxicaciones
Mordedura de Ofidios
Desconoce /No Sabe
Otras
CARPETA FAMILIAR
_________

30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL

0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 5
0 0
0 0
0 0
0 0
0 1
0 0
0 0
0 0
0 0
0 0
0 10
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 15
0 0
0 0
0 0
0 0
0 0
0 0
0 25
0 0
0 2
0 0
0 0
0 0
0 0
0 0
0 3
0 0
0 0
0 5
0 5
0 5
0 0
0 0
0 0
0 0
0 0
0 20
0 0
0 0
0 96
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2
0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0
0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0
0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 9
0 7
0 0
0 2
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 7
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2
0 0
0 5
0 2
0 1
0 0
0
0 0
0
0 0
0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
 0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0
0 0
0
0 0
0 3
0 6
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 3
0 6
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
 INSTRUMENTO DE SISTEMATIZACIÓN ANUAL DE LA CARPETA F
Año: ________________ SEDES__________________ Municipio: _____________________________________ Red de Salud: ______________________________________________
Ambito Geográfico: Urbano Rural Establecimiento: _______________________________________________________
Número de Carpetas Revisadas Comunidad/Localidad/Ciudad/Distrito:
Numeros de Seguimientos de Carpetas Familiares
CARPETAS Completas, Parciales, Bajas
I. DATOS GENERALES (F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
AYMARA
QUECHUA
Hablado CASTELLANO
GUARANI
OTROS
Idiomas
AYMARA
CASTELLANO
Materno QUECHUA
GUARANI
OTROS
<1
1-2
Kilometros
3-4
>4
< 30 minutos
Distancia y tiempo desde la vivienda 30 - 50 minutos
Tiempo a pie
hasta el establecimiento de salud 1 - 2 horas
>2 horas
< 30 minutos
30 - 50 minutos
Tiempo en movilidad
1 - 2 horas
>2 horas
Auxiliar en enfermeria
Cargo del Responsable de llenado Licenciado(a) en enfermeria
Médico(a)
IV. DETERMINANTES DE SALUD (F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
1. Vivienda individual
2. Departamento
A. Tipo de vivienda 3. Cuartos o habitaciones sueltas
4. Choza/Pahuichi/casa rústica
5. Ambiente no destinado para habitar
1. Propia
2. Anticrética
B. Tenencia de 3. Alquiler
Vivienda
4. Cuidador remunerado
5. Otros
1. Una o dos personas
2. Tres
C. No. de personas / 3. Cuatro
cuarto
4. cinco
5. Seis o más
IV. DETERMINANTES DE SALUD (F)
D. Abastecimiento de agua
E. Eliminación de excretas
F. Manejo de Basura
G. Ingreso Familiar
H. Consumo diário de alimentos
I. Nivel de Instrucción de la madre
Rango de riesgo
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
1. Agua por cañería
2. Pileta pública
3. Pozo/Noria/Vertiente/ Cisterna
4. Acequia/río
5.Charcos/ Atajados/Curichi
1. Servicio higiénico en domicilio
2. Servicio higiénico público
3. Letrina
4. Pozo ciego
5. Aire libre
1. Recojo domiciliario
2. Basura enterrada
3. Calle/campo abierto
4. Quemado
5. Río/Quebrada
1. Le permite ahorrar
2. Satisface necesidades
3. Satisface necesidades básicas
4. A veces no alcanza
5. Insuficiente
1. Cons. diario de cereales, tuberculos y derivados
2. Consumo diario de alimentos de origen animal
3. Consumo diario de frutas y verduras
4. Consumo diario de aceite
5. Consumo diario de sal yodada.
1. Universitaria
2. Técnico
3. Secundaria
4. Básica
5. Sin Instrucción
Bajo 28 a 61 puntos
Medio 62 a 126 puntos
Alto 127 a 165 puntos
V. SALUD DE LOS INTEGRANTES DE LA FAMILIA (I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Nro DE INTEGRANTES DE LA FAMILIA
Menores de 5 años 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Mujeres embarazadas
Mayores de 60 años 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Habito de Fumar
Obesidad
Sedentarismo
Factores de Alimentación no adecuada
riesgo
Promiscuidad
Consumo excesivo de alcohol
Consumo de drogas
Problemas de salud
Higiene personal no adecuada
Riesgos laborales
Otros
Tuberculosis(pulmonar y extrapulmonar)
Lepra
Enfermedad de Chagas
Enfermedades VIH / SIDA
Transmisibles
Leishmaniasis
hepatitis
Otras
Neoplasmas malignos
Diabetes mellitus
Hipertensión arterial
Asma
Enfermedades No Cardiopatias(isquèmica, hipertensiva, reumàtica)
Transmisibles Enfermedades del Sistema locomotor(artrosis, artritis)
Enfermedad pulmonar obstructiva crónica
(EPOC)
Insuficiencia renal crónica
Desnutrición crónica
Otras
Intelectual
Fisica
Discapacidad
Sensorial
Multiple

MASCULINO
5-9
FEMENINO
MASCULINO
10-19
FEMENINO
Grupo de Riesgo I
MASCULINO
20-29
FEMENINO
MASCULINO
30-59
FEMENINO
 MASCULINO
<5
FEMENINO
MASCULINO
5-9
FEMENINO
MASCULINO
Problemas de salud 10-19
Grupo de Riesgo FEMENINO
II MASCULINO
20-29
FEMENINO
MASCULINO
30-59
FEMENINO
MASCULINO
60 o +
FEMENINO
MASCULINO
<5
FEMENINO
MASCULINO
5-9
FEMENINO
MASCULINO
10-19
Grupo de Riesgo FEMENINO
III MASCULINO
20-29
FEMENINO
MASCULINO
30-59
FEMENINO
MASCULINO
60 o +
FEMENINO
MASCULINO
<5
FEMENINO
MASCULINO
5-9
FEMENINO
MASCULINO
10-19
Grupo de Riesgo FEMENINO
IV MASCULINO
20-29
FEMENINO
MASCULINO
30-59
FEMENINO
MASCULINO
60 o +
FEMENINO
VI. COMPORTAMIENTO FAMILIAR(F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Violencia intrafamiliar
ACTIVO
Tabaquismo
PASIVO
Maltrato infantil
Consumo excesivo de alcohol
Consumo de drogas
VII. EVALUACIÓN DEL COMPORTAMIENTO FAMILIAR(F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Funcional
Disfuncional
VIII. RESULTADO DE LA EVALUACION DE LA SALUD FAMILIAR(F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Sin problema de salud
Dificultades con los determinantes de salud
Con problema de salud a predominio Dificultades con la salud de los integrantes de la familia
de:
Dificultades en el funcionamiento de la familia

IX. FORMA DE AYUDA FAMILIAR NECESARIA(F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29

Ayuda Educativa
Ayuda Terapéutica
Ayuda Comunitaria
X. ASPECTOS SOCIOCULTURALES (I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Sí
Residencia temporal
No
Sí
Lee No
No Corresponde
Sí 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Escribe No 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
No Corresponde 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Primaria sin concluir
Primaria concluida
Nivel de instrucción Secundaria concluida
Técnico concluido
Universitario concluido
Directivos de gobierno y
empresas 14 o +
Profesionales científicos e
intelectuales
14 o +
Técnicos y profesionales de
nivel medio 14 o +
<14
Empleados de oficina y afines
14 o +
Trabajo de servicios, <14
vendedores y afines 14 o +
Trabajos agrícolas, forestales y <14
afines
14 o +
Artesanos y operarios de <14
oficios 14 o +
Operarios de maquinas e <14
Ocupación instalaciones
 Operarios de maquinas e
Ocupación instalaciones
14 o +
Peones y trabajadores no <14
calificados
14 o +
<14
Fuerzas armadas
14 o +
<14
Sin especificar u otros
14 o +
<14
Estudiante
14 o +
<14
Labores de casa
14 o +

Jubilado o renta dignidad

14 o +

Desempleado
14 o +
Sí
Contribuye a la economía familiar No
No corresponde
XI. MEDICINA TRADICIONAL(I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Siempre
Recurre a la Medicina A veces
Tradicional
Nunca
XII. NACIMIENTOS(I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Masculino
Sexo
Femenino
Dentro Establecimiento
Parto
Fuera Establecimiento
Personal establecimiento
Atendido por Partera
Familiar
Sí
¿Tiene certificación de nacimiento?
No
XIII. DEFUNCIONES (I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Enero
Febrero
Marzo
Abril
Mayo
Junio
Defunciones por mes
Julio
Agosto
Septiembre
Octubre
Noviembre
Diciembre
Institucional
Nro. de Defunciones
No institucional
Neonatal (< 28 días)
Con Certificado de Defunción
Médico
Otorgado por Autoridad
Otro
Sin Certificado de Defunción
XIII. DEFUNCIONES (I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
IRAs
EDAs
Embarazo/ Parto/ Puerperio
Malaria
TB
Corazón
Cáncer
Causa Probable Accidente de Tránsito
Accidente Laboral
Homicidio
Suicidio
Intoxicaciones
Mordedura de Ofidios
Desconoce /No Sabe
Otras
CARPETA FAMILIAR
_________

30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL

0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 5
0 0
0 0
0 0
0 0
0 1
0 0
0 0
0 0
0 0
0 0
0 10
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 15
0 0
0 0
0 0
0 0
0 0
0 0
0 25
0 0
0 2
0 0
0 0
0 0
0 0
0 0
0 3
0 0
0 0
0 5
0 5
0 5
0 0
0 0
0 0
0 0
0 0
0 20
0 0
0 0
0 96
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2
0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0
0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0
0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 9
0 7
0 0
0 2
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 7
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2
0 0
0 5
0 2
0 1
0 0
0
0 0
0
0 0
0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
 0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0
0 0
0
0 0
0 3
0 6
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 3
0 6
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
 INSTRUMENTO DE SISTEMATIZACIÓN ANUAL DE LA CARPETA F
Año: ________________ SEDES__________________ Municipio: _____________________________________ Red de Salud: ______________________________________________
Ambito Geográfico: Urbano Rural Establecimiento: _______________________________________________________
Número de Carpetas Revisadas Comunidad/Localidad/Ciudad/Distrito:
Numeros de Seguimientos de Carpetas Familiares
CARPETAS Completas, Parciales, Bajas
I. DATOS GENERALES (F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
AYMARA
QUECHUA
Hablado CASTELLANO
GUARANI
OTROS
Idiomas
AYMARA
CASTELLANO
Materno QUECHUA
GUARANI
OTROS
<1
1-2
Kilometros
3-4
>4
< 30 minutos
Distancia y tiempo desde la vivienda 30 - 50 minutos
Tiempo a pie
hasta el establecimiento de salud 1 - 2 horas
>2 horas
< 30 minutos
30 - 50 minutos
Tiempo en movilidad
1 - 2 horas
>2 horas
Auxiliar en enfermeria
Cargo del Responsable de llenado Licenciado(a) en enfermeria
Médico(a)
IV. DETERMINANTES DE SALUD (F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
1. Vivienda individual
2. Departamento
A. Tipo de vivienda 3. Cuartos o habitaciones sueltas
4. Choza/Pahuichi/casa rústica
5. Ambiente no destinado para habitar
1. Propia
2. Anticrética
B. Tenencia de 3. Alquiler
Vivienda
4. Cuidador remunerado
5. Otros
1. Una o dos personas
2. Tres
C. No. de personas / 3. Cuatro
cuarto
4. cinco
5. Seis o más
IV. DETERMINANTES DE SALUD (F)
D. Abastecimiento de agua
E. Eliminación de excretas
F. Manejo de Basura
G. Ingreso Familiar
H. Consumo diário de alimentos
I. Nivel de Instrucción de la madre
Rango de riesgo
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
1. Agua por cañería
2. Pileta pública
3. Pozo/Noria/Vertiente/ Cisterna
4. Acequia/río
5.Charcos/ Atajados/Curichi
1. Servicio higiénico en domicilio
2. Servicio higiénico público
3. Letrina
4. Pozo ciego
5. Aire libre
1. Recojo domiciliario
2. Basura enterrada
3. Calle/campo abierto
4. Quemado
5. Río/Quebrada
1. Le permite ahorrar
2. Satisface necesidades
3. Satisface necesidades básicas
4. A veces no alcanza
5. Insuficiente
1. Cons. diario de cereales, tuberculos y derivados
2. Consumo diario de alimentos de origen animal
3. Consumo diario de frutas y verduras
4. Consumo diario de aceite
5. Consumo diario de sal yodada.
1. Universitaria
2. Técnico
3. Secundaria
4. Básica
5. Sin Instrucción
Bajo 28 a 61 puntos
Medio 62 a 126 puntos
Alto 127 a 165 puntos
V. SALUD DE LOS INTEGRANTES DE LA FAMILIA (I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Nro DE INTEGRANTES DE LA FAMILIA
Menores de 5 años 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Mujeres embarazadas
Mayores de 60 años 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Habito de Fumar
Obesidad
Sedentarismo
Factores de Alimentación no adecuada
riesgo
Promiscuidad
Consumo excesivo de alcohol
Consumo de drogas
Problemas de salud
Higiene personal no adecuada
Riesgos laborales
Otros
Tuberculosis(pulmonar y extrapulmonar)
Lepra
Enfermedad de Chagas
Enfermedades VIH / SIDA
Transmisibles
Leishmaniasis
hepatitis
Otras
Neoplasmas malignos
Diabetes mellitus
Hipertensión arterial
Asma
Enfermedades No Cardiopatias(isquèmica, hipertensiva, reumàtica)
Transmisibles Enfermedades del Sistema locomotor(artrosis, artritis)
Enfermedad pulmonar obstructiva crónica
(EPOC)
Insuficiencia renal crónica
Desnutrición crónica
Otras
Intelectual
Fisica
Discapacidad
Sensorial
Multiple

MASCULINO
5-9
FEMENINO
MASCULINO
10-19
FEMENINO
Grupo de Riesgo I
MASCULINO
20-29
FEMENINO
MASCULINO
30-59
FEMENINO
 MASCULINO
<5
FEMENINO
MASCULINO
5-9
FEMENINO
MASCULINO
Problemas de salud 10-19
Grupo de Riesgo FEMENINO
II MASCULINO
20-29
FEMENINO
MASCULINO
30-59
FEMENINO
MASCULINO
60 o +
FEMENINO
MASCULINO
<5
FEMENINO
MASCULINO
5-9
FEMENINO
MASCULINO
10-19
Grupo de Riesgo FEMENINO
III MASCULINO
20-29
FEMENINO
MASCULINO
30-59
FEMENINO
MASCULINO
60 o +
FEMENINO
MASCULINO
<5
FEMENINO
MASCULINO
5-9
FEMENINO
MASCULINO
10-19
Grupo de Riesgo FEMENINO
IV MASCULINO
20-29
FEMENINO
MASCULINO
30-59
FEMENINO
MASCULINO
60 o +
FEMENINO
VI. COMPORTAMIENTO FAMILIAR(F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Violencia intrafamiliar
ACTIVO
Tabaquismo
PASIVO
Maltrato infantil
Consumo excesivo de alcohol
Consumo de drogas
VII. EVALUACIÓN DEL COMPORTAMIENTO FAMILIAR(F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Funcional
Disfuncional
VIII. RESULTADO DE LA EVALUACION DE LA SALUD FAMILIAR(F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Sin problema de salud
Dificultades con los determinantes de salud
Con problema de salud a predominio Dificultades con la salud de los integrantes de la familia
de:
Dificultades en el funcionamiento de la familia

IX. FORMA DE AYUDA FAMILIAR NECESARIA(F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29

Ayuda Educativa
Ayuda Terapéutica
Ayuda Comunitaria
X. ASPECTOS SOCIOCULTURALES (I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Sí
Residencia temporal
No
Sí
Lee No
No Corresponde
Sí 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Escribe No 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
No Corresponde 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Primaria sin concluir
Primaria concluida
Nivel de instrucción Secundaria concluida
Técnico concluido
Universitario concluido
Directivos de gobierno y
empresas 14 o +
Profesionales científicos e
intelectuales
14 o +
Técnicos y profesionales de
nivel medio 14 o +
<14
Empleados de oficina y afines
14 o +
Trabajo de servicios, <14
vendedores y afines 14 o +
Trabajos agrícolas, forestales y <14
afines
14 o +
Artesanos y operarios de <14
oficios 14 o +
Operarios de maquinas e <14
Ocupación instalaciones
 Operarios de maquinas e
Ocupación instalaciones
14 o +
Peones y trabajadores no <14
calificados
14 o +
<14
Fuerzas armadas
14 o +
<14
Sin especificar u otros
14 o +
<14
Estudiante
14 o +
<14
Labores de casa
14 o +

Jubilado o renta dignidad

14 o +

Desempleado
14 o +
Sí
Contribuye a la economía familiar No
No corresponde
XI. MEDICINA TRADICIONAL(I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Siempre
Recurre a la Medicina A veces
Tradicional
Nunca
XII. NACIMIENTOS(I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Masculino
Sexo
Femenino
Dentro Establecimiento
Parto
Fuera Establecimiento
Personal establecimiento
Atendido por Partera
Familiar
Sí
¿Tiene certificación de nacimiento?
No
XIII. DEFUNCIONES (I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Enero
Febrero
Marzo
Abril
Mayo
Junio
Defunciones por mes
Julio
Agosto
Septiembre
Octubre
Noviembre
Diciembre
Institucional
Nro. de Defunciones
No institucional
Neonatal (< 28 días)
Con Certificado de Defunción
Médico
Otorgado por Autoridad
Otro
Sin Certificado de Defunción
XIII. DEFUNCIONES (I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
IRAs
EDAs
Embarazo/ Parto/ Puerperio
Malaria
TB
Corazón
Cáncer
Causa Probable Accidente de Tránsito
Accidente Laboral
Homicidio
Suicidio
Intoxicaciones
Mordedura de Ofidios
Desconoce /No Sabe
Otras
CARPETA FAMILIAR
_________

30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL

0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 5
0 0
0 0
0 0
0 0
0 1
0 0
0 0
0 0
0 0
0 0
0 10
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 15
0 0
0 0
0 0
0 0
0 0
0 0
0 25
0 0
0 2
0 0
0 0
0 0
0 0
0 0
0 3
0 0
0 0
0 5
0 5
0 5
0 0
0 0
0 0
0 0
0 0
0 20
0 0
0 0
0 96
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2
0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0
0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0
0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 9
0 7
0 0
0 2
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 7
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2
0 0
0 5
0 2
0 1
0 0
0
0 0
0
0 0
0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
 0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0
0 0
0
0 0
0 3
0 6
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 3
0 6
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
 INSTRUMENTO DE SISTEMATIZACIÓN ANUAL DE LA CARPETA F
Año: ________________ SEDES__________________ Municipio: _____________________________________ Red de Salud: ______________________________________________
Ambito Geográfico: Urbano Rural Establecimiento: _______________________________________________________
Número de Carpetas Revisadas Comunidad/Localidad/Ciudad/Distrito:
Numeros de Seguimientos de Carpetas Familiares
CARPETAS Completas, Parciales, Bajas
I. DATOS GENERALES (F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
AYMARA
QUECHUA
Hablado CASTELLANO
GUARANI
OTROS
Idiomas
AYMARA
CASTELLANO
Materno QUECHUA
GUARANI
OTROS
<1
1-2
Kilometros
3-4
>4
< 30 minutos
Distancia y tiempo desde la vivienda 30 - 50 minutos
Tiempo a pie
hasta el establecimiento de salud 1 - 2 horas
>2 horas
< 30 minutos
30 - 50 minutos
Tiempo en movilidad
1 - 2 horas
>2 horas
Auxiliar en enfermeria
Cargo del Responsable de llenado Licenciado(a) en enfermeria
Médico(a)
IV. DETERMINANTES DE SALUD (F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
1. Vivienda individual
2. Departamento
A. Tipo de vivienda 3. Cuartos o habitaciones sueltas
4. Choza/Pahuichi/casa rústica
5. Ambiente no destinado para habitar
1. Propia
2. Anticrética
B. Tenencia de 3. Alquiler
Vivienda
4. Cuidador remunerado
5. Otros
1. Una o dos personas
2. Tres
C. No. de personas / 3. Cuatro
cuarto
4. cinco
5. Seis o más
IV. DETERMINANTES DE SALUD (F)
D. Abastecimiento de agua
E. Eliminación de excretas
F. Manejo de Basura
G. Ingreso Familiar
H. Consumo diário de alimentos
I. Nivel de Instrucción de la madre
Rango de riesgo
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
1. Agua por cañería
2. Pileta pública
3. Pozo/Noria/Vertiente/ Cisterna
4. Acequia/río
5.Charcos/ Atajados/Curichi
1. Servicio higiénico en domicilio
2. Servicio higiénico público
3. Letrina
4. Pozo ciego
5. Aire libre
1. Recojo domiciliario
2. Basura enterrada
3. Calle/campo abierto
4. Quemado
5. Río/Quebrada
1. Le permite ahorrar
2. Satisface necesidades
3. Satisface necesidades básicas
4. A veces no alcanza
5. Insuficiente
1. Cons. diario de cereales, tuberculos y derivados
2. Consumo diario de alimentos de origen animal
3. Consumo diario de frutas y verduras
4. Consumo diario de aceite
5. Consumo diario de sal yodada.
1. Universitaria
2. Técnico
3. Secundaria
4. Básica
5. Sin Instrucción
Bajo 28 a 61 puntos
Medio 62 a 126 puntos
Alto 127 a 165 puntos
V. SALUD DE LOS INTEGRANTES DE LA FAMILIA (I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Nro DE INTEGRANTES DE LA FAMILIA
Menores de 5 años 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Mujeres embarazadas
Mayores de 60 años 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Habito de Fumar
Obesidad
Sedentarismo
Factores de Alimentación no adecuada
riesgo
Promiscuidad
Consumo excesivo de alcohol
Consumo de drogas
Problemas de salud
Higiene personal no adecuada
Riesgos laborales
Otros
Tuberculosis(pulmonar y extrapulmonar)
Lepra
Enfermedad de Chagas
Enfermedades VIH / SIDA
Transmisibles
Leishmaniasis
hepatitis
Otras
Neoplasmas malignos
Diabetes mellitus
Hipertensión arterial
Asma
Enfermedades No Cardiopatias(isquèmica, hipertensiva, reumàtica)
Transmisibles Enfermedades del Sistema locomotor(artrosis, artritis)
Enfermedad pulmonar obstructiva crónica
(EPOC)
Insuficiencia renal crónica
Desnutrición crónica
Otras
Intelectual
Fisica
Discapacidad
Sensorial
Multiple

MASCULINO
5-9
FEMENINO
MASCULINO
10-19
FEMENINO
Grupo de Riesgo I
MASCULINO
20-29
FEMENINO
MASCULINO
30-59
FEMENINO
 MASCULINO
<5
FEMENINO
MASCULINO
5-9
FEMENINO
MASCULINO
Problemas de salud 10-19
Grupo de Riesgo FEMENINO
II MASCULINO
20-29
FEMENINO
MASCULINO
30-59
FEMENINO
MASCULINO
60 o +
FEMENINO
MASCULINO
<5
FEMENINO
MASCULINO
5-9
FEMENINO
MASCULINO
10-19
Grupo de Riesgo FEMENINO
III MASCULINO
20-29
FEMENINO
MASCULINO
30-59
FEMENINO
MASCULINO
60 o +
FEMENINO
MASCULINO
<5
FEMENINO
MASCULINO
5-9
FEMENINO
MASCULINO
10-19
Grupo de Riesgo FEMENINO
IV MASCULINO
20-29
FEMENINO
MASCULINO
30-59
FEMENINO
MASCULINO
60 o +
FEMENINO
VI. COMPORTAMIENTO FAMILIAR(F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Violencia intrafamiliar
ACTIVO
Tabaquismo
PASIVO
Maltrato infantil
Consumo excesivo de alcohol
Consumo de drogas
VII. EVALUACIÓN DEL COMPORTAMIENTO FAMILIAR(F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Funcional
Disfuncional
VIII. RESULTADO DE LA EVALUACION DE LA SALUD FAMILIAR(F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Sin problema de salud
Dificultades con los determinantes de salud
Con problema de salud a predominio Dificultades con la salud de los integrantes de la familia
de:
Dificultades en el funcionamiento de la familia

IX. FORMA DE AYUDA FAMILIAR NECESARIA(F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29

Ayuda Educativa
Ayuda Terapéutica
Ayuda Comunitaria
X. ASPECTOS SOCIOCULTURALES (I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Sí
Residencia temporal
No
Sí
Lee No
No Corresponde
Sí 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Escribe No 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
No Corresponde 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Primaria sin concluir
Primaria concluida
Nivel de instrucción Secundaria concluida
Técnico concluido
Universitario concluido
Directivos de gobierno y
empresas 14 o +
Profesionales científicos e
intelectuales
14 o +
Técnicos y profesionales de
nivel medio 14 o +
<14
Empleados de oficina y afines
14 o +
Trabajo de servicios, <14
vendedores y afines 14 o +
Trabajos agrícolas, forestales y <14
afines
14 o +
Artesanos y operarios de <14
oficios 14 o +
Operarios de maquinas e <14
Ocupación instalaciones
 Operarios de maquinas e
Ocupación instalaciones
14 o +
Peones y trabajadores no <14
calificados
14 o +
<14
Fuerzas armadas
14 o +
<14
Sin especificar u otros
14 o +
<14
Estudiante
14 o +
<14
Labores de casa
14 o +

Jubilado o renta dignidad

14 o +

Desempleado
14 o +
Sí
Contribuye a la economía familiar No
No corresponde
XI. MEDICINA TRADICIONAL(I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Siempre
Recurre a la Medicina A veces
Tradicional
Nunca
XII. NACIMIENTOS(I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Masculino
Sexo
Femenino
Dentro Establecimiento
Parto
Fuera Establecimiento
Personal establecimiento
Atendido por Partera
Familiar
Sí
¿Tiene certificación de nacimiento?
No
XIII. DEFUNCIONES (I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Enero
Febrero
Marzo
Abril
Mayo
Junio
Defunciones por mes
Julio
Agosto
Septiembre
Octubre
Noviembre
Diciembre
Institucional
Nro. de Defunciones
No institucional
Neonatal (< 28 días)
Con Certificado de Defunción
Médico
Otorgado por Autoridad
Otro
Sin Certificado de Defunción
XIII. DEFUNCIONES (I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
IRAs
EDAs
Embarazo/ Parto/ Puerperio
Malaria
TB
Corazón
Cáncer
Causa Probable Accidente de Tránsito
Accidente Laboral
Homicidio
Suicidio
Intoxicaciones
Mordedura de Ofidios
Desconoce /No Sabe
Otras
CARPETA FAMILIAR
_________

30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL

0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 5
0 0
0 0
0 0
0 0
0 1
0 0
0 0
0 0
0 0
0 0
0 10
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 15
0 0
0 0
0 0
0 0
0 0
0 0
0 25
0 0
0 2
0 0
0 0
0 0
0 0
0 0
0 3
0 0
0 0
0 5
0 5
0 5
0 0
0 0
0 0
0 0
0 0
0 20
0 0
0 0
0 96
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2
0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0
0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0
0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 9
0 7
0 0
0 2
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 7
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2
0 0
0 5
0 2
0 1
0 0
0
0 0
0
0 0
0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
 0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0
0 0
0
0 0
0 3
0 6
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 3
0 6
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
 INSTRUMENTO DE SISTEMATIZACIÓN ANUAL DE LA CARPETA F
Año: ________________ SEDES__________________ Municipio: _____________________________________ Red de Salud: ______________________________________________
Ambito Geográfico: Urbano Rural Establecimiento: _______________________________________________________
Número de Carpetas Revisadas Comunidad/Localidad/Ciudad/Distrito:
Numeros de Seguimientos de Carpetas Familiares
CARPETAS Completas, Parciales, Bajas
I. DATOS GENERALES (F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
AYMARA
QUECHUA
Hablado CASTELLANO
GUARANI
OTROS
Idiomas
AYMARA
CASTELLANO
Materno QUECHUA
GUARANI
OTROS
<1
1-2
Kilometros
3-4
>4
< 30 minutos
Distancia y tiempo desde la vivienda 30 - 50 minutos
Tiempo a pie
hasta el establecimiento de salud 1 - 2 horas
>2 horas
< 30 minutos
30 - 50 minutos
Tiempo en movilidad
1 - 2 horas
>2 horas
Auxiliar en enfermeria
Cargo del Responsable de llenado Licenciado(a) en enfermeria
Médico(a)
IV. DETERMINANTES DE SALUD (F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
1. Vivienda individual
2. Departamento
A. Tipo de vivienda 3. Cuartos o habitaciones sueltas
4. Choza/Pahuichi/casa rústica
5. Ambiente no destinado para habitar
1. Propia
2. Anticrética
B. Tenencia de 3. Alquiler
Vivienda
4. Cuidador remunerado
5. Otros
1. Una o dos personas
2. Tres
C. No. de personas / 3. Cuatro
cuarto
4. cinco
5. Seis o más
IV. DETERMINANTES DE SALUD (F)
D. Abastecimiento de agua
E. Eliminación de excretas
F. Manejo de Basura
G. Ingreso Familiar
H. Consumo diário de alimentos
I. Nivel de Instrucción de la madre
Rango de riesgo
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
1. Agua por cañería
2. Pileta pública
3. Pozo/Noria/Vertiente/ Cisterna
4. Acequia/río
5.Charcos/ Atajados/Curichi
1. Servicio higiénico en domicilio
2. Servicio higiénico público
3. Letrina
4. Pozo ciego
5. Aire libre
1. Recojo domiciliario
2. Basura enterrada
3. Calle/campo abierto
4. Quemado
5. Río/Quebrada
1. Le permite ahorrar
2. Satisface necesidades
3. Satisface necesidades básicas
4. A veces no alcanza
5. Insuficiente
1. Cons. diario de cereales, tuberculos y derivados
2. Consumo diario de alimentos de origen animal
3. Consumo diario de frutas y verduras
4. Consumo diario de aceite
5. Consumo diario de sal yodada.
1. Universitaria
2. Técnico
3. Secundaria
4. Básica
5. Sin Instrucción
Bajo 28 a 61 puntos
Medio 62 a 126 puntos
Alto 127 a 165 puntos
V. SALUD DE LOS INTEGRANTES DE LA FAMILIA (I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Nro DE INTEGRANTES DE LA FAMILIA
Menores de 5 años 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Mujeres embarazadas
Mayores de 60 años 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Habito de Fumar
Obesidad
Sedentarismo
Factores de Alimentación no adecuada
riesgo
Promiscuidad
Consumo excesivo de alcohol
Consumo de drogas
Problemas de salud
Higiene personal no adecuada
Riesgos laborales
Otros
Tuberculosis(pulmonar y extrapulmonar)
Lepra
Enfermedad de Chagas
Enfermedades VIH / SIDA
Transmisibles
Leishmaniasis
hepatitis
Otras
Neoplasmas malignos
Diabetes mellitus
Hipertensión arterial
Asma
Enfermedades No Cardiopatias(isquèmica, hipertensiva, reumàtica)
Transmisibles Enfermedades del Sistema locomotor(artrosis, artritis)
Enfermedad pulmonar obstructiva crónica
(EPOC)
Insuficiencia renal crónica
Desnutrición crónica
Otras
Intelectual
Fisica
Discapacidad
Sensorial
Multiple

MASCULINO
5-9
FEMENINO
MASCULINO
10-19
FEMENINO
Grupo de Riesgo I
MASCULINO
20-29
FEMENINO
MASCULINO
30-59
FEMENINO
 MASCULINO
<5
FEMENINO
MASCULINO
5-9
FEMENINO
MASCULINO
Problemas de salud 10-19
Grupo de Riesgo FEMENINO
II MASCULINO
20-29
FEMENINO
MASCULINO
30-59
FEMENINO
MASCULINO
60 o +
FEMENINO
MASCULINO
<5
FEMENINO
MASCULINO
5-9
FEMENINO
MASCULINO
10-19
Grupo de Riesgo FEMENINO
III MASCULINO
20-29
FEMENINO
MASCULINO
30-59
FEMENINO
MASCULINO
60 o +
FEMENINO
MASCULINO
<5
FEMENINO
MASCULINO
5-9
FEMENINO
MASCULINO
10-19
Grupo de Riesgo FEMENINO
IV MASCULINO
20-29
FEMENINO
MASCULINO
30-59
FEMENINO
MASCULINO
60 o +
FEMENINO
VI. COMPORTAMIENTO FAMILIAR(F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Violencia intrafamiliar
ACTIVO
Tabaquismo
PASIVO
Maltrato infantil
Consumo excesivo de alcohol
Consumo de drogas
VII. EVALUACIÓN DEL COMPORTAMIENTO FAMILIAR(F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Funcional
Disfuncional
VIII. RESULTADO DE LA EVALUACION DE LA SALUD FAMILIAR(F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Sin problema de salud
Dificultades con los determinantes de salud
Con problema de salud a predominio Dificultades con la salud de los integrantes de la familia
de:
Dificultades en el funcionamiento de la familia

IX. FORMA DE AYUDA FAMILIAR NECESARIA(F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29

Ayuda Educativa
Ayuda Terapéutica
Ayuda Comunitaria
X. ASPECTOS SOCIOCULTURALES (I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Sí
Residencia temporal
No
Sí
Lee No
No Corresponde
Sí 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Escribe No 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
No Corresponde 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Primaria sin concluir
Primaria concluida
Nivel de instrucción Secundaria concluida
Técnico concluido
Universitario concluido
Directivos de gobierno y
empresas 14 o +
Profesionales científicos e
intelectuales
14 o +
Técnicos y profesionales de
nivel medio 14 o +
<14
Empleados de oficina y afines
14 o +
Trabajo de servicios, <14
vendedores y afines 14 o +
Trabajos agrícolas, forestales y <14
afines
14 o +
Artesanos y operarios de <14
oficios 14 o +
Operarios de maquinas e <14
Ocupación instalaciones
 Operarios de maquinas e
Ocupación instalaciones
14 o +
Peones y trabajadores no <14
calificados
14 o +
<14
Fuerzas armadas
14 o +
<14
Sin especificar u otros
14 o +
<14
Estudiante
14 o +
<14
Labores de casa
14 o +

Jubilado o renta dignidad

14 o +

Desempleado
14 o +
Sí
Contribuye a la economía familiar No
No corresponde
XI. MEDICINA TRADICIONAL(I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Siempre
Recurre a la Medicina A veces
Tradicional
Nunca
XII. NACIMIENTOS(I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Masculino
Sexo
Femenino
Dentro Establecimiento
Parto
Fuera Establecimiento
Personal establecimiento
Atendido por Partera
Familiar
Sí
¿Tiene certificación de nacimiento?
No
XIII. DEFUNCIONES (I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Enero
Febrero
Marzo
Abril
Mayo
Junio
Defunciones por mes
Julio
Agosto
Septiembre
Octubre
Noviembre
Diciembre
Institucional
Nro. de Defunciones
No institucional
Neonatal (< 28 días)
Con Certificado de Defunción
Médico
Otorgado por Autoridad
Otro
Sin Certificado de Defunción
XIII. DEFUNCIONES (I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
IRAs
EDAs
Embarazo/ Parto/ Puerperio
Malaria
TB
Corazón
Cáncer
Causa Probable Accidente de Tránsito
Accidente Laboral
Homicidio
Suicidio
Intoxicaciones
Mordedura de Ofidios
Desconoce /No Sabe
Otras
CARPETA FAMILIAR
_________

30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL

0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 5
0 0
0 0
0 0
0 0
0 1
0 0
0 0
0 0
0 0
0 0
0 10
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 15
0 0
0 0
0 0
0 0
0 0
0 0
0 25
0 0
0 2
0 0
0 0
0 0
0 0
0 0
0 3
0 0
0 0
0 5
0 5
0 5
0 0
0 0
0 0
0 0
0 0
0 20
0 0
0 0
0 96
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2
0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0
0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0
0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 9
0 7
0 0
0 2
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 7
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2
0 0
0 5
0 2
0 1
0 0
0
0 0
0
0 0
0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
 0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0
0 0
0
0 0
0 3
0 6
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 3
0 6
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
 INSTRUMENTO DE SISTEMATIZACIÓN ANUAL DE LA CARPETA F
Año: ________________ SEDES__________________ Municipio: _____________________________________ Red de Salud: ______________________________________________
Ambito Geográfico: Urbano Rural Establecimiento: _______________________________________________________
Número de Carpetas Revisadas Comunidad/Localidad/Ciudad/Distrito:
Numeros de Seguimientos de Carpetas Familiares
CARPETAS Completas, Parciales, Bajas
I. DATOS GENERALES (F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
AYMARA
QUECHUA
Hablado CASTELLANO
GUARANI
OTROS
Idiomas
AYMARA
CASTELLANO
Materno QUECHUA
GUARANI
OTROS
<1
1-2
Kilometros
3-4
>4
< 30 minutos
Distancia y tiempo desde la vivienda 30 - 50 minutos
Tiempo a pie
hasta el establecimiento de salud 1 - 2 horas
>2 horas
< 30 minutos
30 - 50 minutos
Tiempo en movilidad
1 - 2 horas
>2 horas
Auxiliar en enfermeria
Cargo del Responsable de llenado Licenciado(a) en enfermeria
Médico(a)
IV. DETERMINANTES DE SALUD (F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
1. Vivienda individual
2. Departamento
A. Tipo de vivienda 3. Cuartos o habitaciones sueltas
4. Choza/Pahuichi/casa rústica
5. Ambiente no destinado para habitar
1. Propia
2. Anticrética
B. Tenencia de 3. Alquiler
Vivienda
4. Cuidador remunerado
5. Otros
1. Una o dos personas
2. Tres
C. No. de personas / 3. Cuatro
cuarto
4. cinco
5. Seis o más
IV. DETERMINANTES DE SALUD (F)
D. Abastecimiento de agua
E. Eliminación de excretas
F. Manejo de Basura
G. Ingreso Familiar
H. Consumo diário de alimentos
I. Nivel de Instrucción de la madre
Rango de riesgo
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
1. Agua por cañería
2. Pileta pública
3. Pozo/Noria/Vertiente/ Cisterna
4. Acequia/río
5.Charcos/ Atajados/Curichi
1. Servicio higiénico en domicilio
2. Servicio higiénico público
3. Letrina
4. Pozo ciego
5. Aire libre
1. Recojo domiciliario
2. Basura enterrada
3. Calle/campo abierto
4. Quemado
5. Río/Quebrada
1. Le permite ahorrar
2. Satisface necesidades
3. Satisface necesidades básicas
4. A veces no alcanza
5. Insuficiente
1. Cons. diario de cereales, tuberculos y derivados
2. Consumo diario de alimentos de origen animal
3. Consumo diario de frutas y verduras
4. Consumo diario de aceite
5. Consumo diario de sal yodada.
1. Universitaria
2. Técnico
3. Secundaria
4. Básica
5. Sin Instrucción
Bajo 28 a 61 puntos
Medio 62 a 126 puntos
Alto 127 a 165 puntos
V. SALUD DE LOS INTEGRANTES DE LA FAMILIA (I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Nro DE INTEGRANTES DE LA FAMILIA
Menores de 5 años 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Mujeres embarazadas
Mayores de 60 años 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Habito de Fumar
Obesidad
Sedentarismo
Factores de Alimentación no adecuada
riesgo
Promiscuidad
Consumo excesivo de alcohol
Consumo de drogas
Problemas de salud
Higiene personal no adecuada
Riesgos laborales
Otros
Tuberculosis(pulmonar y extrapulmonar)
Lepra
Enfermedad de Chagas
Enfermedades VIH / SIDA
Transmisibles
Leishmaniasis
hepatitis
Otras
Neoplasmas malignos
Diabetes mellitus
Hipertensión arterial
Asma
Enfermedades No Cardiopatias(isquèmica, hipertensiva, reumàtica)
Transmisibles Enfermedades del Sistema locomotor(artrosis, artritis)
Enfermedad pulmonar obstructiva crónica
(EPOC)
Insuficiencia renal crónica
Desnutrición crónica
Otras
Intelectual
Fisica
Discapacidad
Sensorial
Multiple

MASCULINO
5-9
FEMENINO
MASCULINO
10-19
FEMENINO
Grupo de Riesgo I
MASCULINO
20-29
FEMENINO
MASCULINO
30-59
FEMENINO
 MASCULINO
<5
FEMENINO
MASCULINO
5-9
FEMENINO
MASCULINO
Problemas de salud 10-19
Grupo de Riesgo FEMENINO
II MASCULINO
20-29
FEMENINO
MASCULINO
30-59
FEMENINO
MASCULINO
60 o +
FEMENINO
MASCULINO
<5
FEMENINO
MASCULINO
5-9
FEMENINO
MASCULINO
10-19
Grupo de Riesgo FEMENINO
III MASCULINO
20-29
FEMENINO
MASCULINO
30-59
FEMENINO
MASCULINO
60 o +
FEMENINO
MASCULINO
<5
FEMENINO
MASCULINO
5-9
FEMENINO
MASCULINO
10-19
Grupo de Riesgo FEMENINO
IV MASCULINO
20-29
FEMENINO
MASCULINO
30-59
FEMENINO
MASCULINO
60 o +
FEMENINO
VI. COMPORTAMIENTO FAMILIAR(F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Violencia intrafamiliar
ACTIVO
Tabaquismo
PASIVO
Maltrato infantil
Consumo excesivo de alcohol
Consumo de drogas
VII. EVALUACIÓN DEL COMPORTAMIENTO FAMILIAR(F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Funcional
Disfuncional
VIII. RESULTADO DE LA EVALUACION DE LA SALUD FAMILIAR(F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Sin problema de salud
Dificultades con los determinantes de salud
Con problema de salud a predominio Dificultades con la salud de los integrantes de la familia
de:
Dificultades en el funcionamiento de la familia

IX. FORMA DE AYUDA FAMILIAR NECESARIA(F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29

Ayuda Educativa
Ayuda Terapéutica
Ayuda Comunitaria
X. ASPECTOS SOCIOCULTURALES (I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Sí
Residencia temporal
No
Sí
Lee No
No Corresponde
Sí 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Escribe No 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
No Corresponde 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Primaria sin concluir
Primaria concluida
Nivel de instrucción Secundaria concluida
Técnico concluido
Universitario concluido
Directivos de gobierno y
empresas 14 o +
Profesionales científicos e
intelectuales
14 o +
Técnicos y profesionales de
nivel medio 14 o +
<14
Empleados de oficina y afines
14 o +
Trabajo de servicios, <14
vendedores y afines 14 o +
Trabajos agrícolas, forestales y <14
afines
14 o +
Artesanos y operarios de <14
oficios 14 o +
Operarios de maquinas e <14
Ocupación instalaciones
 Operarios de maquinas e
Ocupación instalaciones
14 o +
Peones y trabajadores no <14
calificados
14 o +
<14
Fuerzas armadas
14 o +
<14
Sin especificar u otros
14 o +
<14
Estudiante
14 o +
<14
Labores de casa
14 o +

Jubilado o renta dignidad

14 o +

Desempleado
14 o +
Sí
Contribuye a la economía familiar No
No corresponde
XI. MEDICINA TRADICIONAL(I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Siempre
Recurre a la Medicina A veces
Tradicional
Nunca
XII. NACIMIENTOS(I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Masculino
Sexo
Femenino
Dentro Establecimiento
Parto
Fuera Establecimiento
Personal establecimiento
Atendido por Partera
Familiar
Sí
¿Tiene certificación de nacimiento?
No
XIII. DEFUNCIONES (I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Enero
Febrero
Marzo
Abril
Mayo
Junio
Defunciones por mes
Julio
Agosto
Septiembre
Octubre
Noviembre
Diciembre
Institucional
Nro. de Defunciones
No institucional
Neonatal (< 28 días)
Con Certificado de Defunción
Médico
Otorgado por Autoridad
Otro
Sin Certificado de Defunción
XIII. DEFUNCIONES (I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
IRAs
EDAs
Embarazo/ Parto/ Puerperio
Malaria
TB
Corazón
Cáncer
Causa Probable Accidente de Tránsito
Accidente Laboral
Homicidio
Suicidio
Intoxicaciones
Mordedura de Ofidios
Desconoce /No Sabe
Otras
CARPETA FAMILIAR
_________

30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL

0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 5
0 0
0 0
0 0
0 0
0 1
0 0
0 0
0 0
0 0
0 0
0 10
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 15
0 0
0 0
0 0
0 0
0 0
0 0
0 25
0 0
0 2
0 0
0 0
0 0
0 0
0 0
0 3
0 0
0 0
0 5
0 5
0 5
0 0
0 0
0 0
0 0
0 0
0 20
0 0
0 0
0 96
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2
0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0
0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0
0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 9
0 7
0 0
0 2
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 7
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2
0 0
0 5
0 2
0 1
0 0
0
0 0
0
0 0
0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
 0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0
0 0
0
0 0
0 3
0 6
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 3
0 6
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
 INSTRUMENTO DE SISTEMATIZACIÓN ANUAL DE LA CARPETA F
Año: ________________ SEDES__________________ Municipio: _____________________________________ Red de Salud: ______________________________________________
Ambito Geográfico: Urbano Rural Establecimiento: _______________________________________________________
Número de Carpetas Revisadas Comunidad/Localidad/Ciudad/Distrito:
Numeros de Seguimientos de Carpetas Familiares
CARPETAS Completas, Parciales, Bajas
I. DATOS GENERALES (F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
AYMARA
QUECHUA
Hablado CASTELLANO
GUARANI
OTROS
Idiomas
AYMARA
CASTELLANO
Materno QUECHUA
GUARANI
OTROS
<1
1-2
Kilometros
3-4
>4
< 30 minutos
Distancia y tiempo desde la vivienda 30 - 50 minutos
Tiempo a pie
hasta el establecimiento de salud 1 - 2 horas
>2 horas
< 30 minutos
30 - 50 minutos
Tiempo en movilidad
1 - 2 horas
>2 horas
Auxiliar en enfermeria
Cargo del Responsable de llenado Licenciado(a) en enfermeria
Médico(a)
IV. DETERMINANTES DE SALUD (F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
1. Vivienda individual
2. Departamento
A. Tipo de vivienda 3. Cuartos o habitaciones sueltas
4. Choza/Pahuichi/casa rústica
5. Ambiente no destinado para habitar
1. Propia
2. Anticrética
B. Tenencia de 3. Alquiler
Vivienda
4. Cuidador remunerado
5. Otros
1. Una o dos personas
2. Tres
C. No. de personas / 3. Cuatro
cuarto
4. cinco
5. Seis o más
IV. DETERMINANTES DE SALUD (F)
D. Abastecimiento de agua
E. Eliminación de excretas
F. Manejo de Basura
G. Ingreso Familiar
H. Consumo diário de alimentos
I. Nivel de Instrucción de la madre
Rango de riesgo
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
1. Agua por cañería
2. Pileta pública
3. Pozo/Noria/Vertiente/ Cisterna
4. Acequia/río
5.Charcos/ Atajados/Curichi
1. Servicio higiénico en domicilio
2. Servicio higiénico público
3. Letrina
4. Pozo ciego
5. Aire libre
1. Recojo domiciliario
2. Basura enterrada
3. Calle/campo abierto
4. Quemado
5. Río/Quebrada
1. Le permite ahorrar
2. Satisface necesidades
3. Satisface necesidades básicas
4. A veces no alcanza
5. Insuficiente
1. Cons. diario de cereales, tuberculos y derivados
2. Consumo diario de alimentos de origen animal
3. Consumo diario de frutas y verduras
4. Consumo diario de aceite
5. Consumo diario de sal yodada.
1. Universitaria
2. Técnico
3. Secundaria
4. Básica
5. Sin Instrucción
Bajo 28 a 61 puntos
Medio 62 a 126 puntos
Alto 127 a 165 puntos
V. SALUD DE LOS INTEGRANTES DE LA FAMILIA (I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Nro DE INTEGRANTES DE LA FAMILIA
Menores de 5 años 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Mujeres embarazadas
Mayores de 60 años 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Habito de Fumar
Obesidad
Sedentarismo
Factores de Alimentación no adecuada
riesgo
Promiscuidad
Consumo excesivo de alcohol
Consumo de drogas
Problemas de salud
Higiene personal no adecuada
Riesgos laborales
Otros
Tuberculosis(pulmonar y extrapulmonar)
Lepra
Enfermedad de Chagas
Enfermedades VIH / SIDA
Transmisibles
Leishmaniasis
hepatitis
Otras
Neoplasmas malignos
Diabetes mellitus
Hipertensión arterial
Asma
Enfermedades No Cardiopatias(isquèmica, hipertensiva, reumàtica)
Transmisibles Enfermedades del Sistema locomotor(artrosis, artritis)
Enfermedad pulmonar obstructiva crónica
(EPOC)
Insuficiencia renal crónica
Desnutrición crónica
Otras
Intelectual
Fisica
Discapacidad
Sensorial
Multiple

MASCULINO
5-9
FEMENINO
MASCULINO
10-19
FEMENINO
Grupo de Riesgo I
MASCULINO
20-29
FEMENINO
MASCULINO
30-59
FEMENINO
 MASCULINO
<5
FEMENINO
MASCULINO
5-9
FEMENINO
MASCULINO
Problemas de salud 10-19
Grupo de Riesgo FEMENINO
II MASCULINO
20-29
FEMENINO
MASCULINO
30-59
FEMENINO
MASCULINO
60 o +
FEMENINO
MASCULINO
<5
FEMENINO
MASCULINO
5-9
FEMENINO
MASCULINO
10-19
Grupo de Riesgo FEMENINO
III MASCULINO
20-29
FEMENINO
MASCULINO
30-59
FEMENINO
MASCULINO
60 o +
FEMENINO
MASCULINO
<5
FEMENINO
MASCULINO
5-9
FEMENINO
MASCULINO
10-19
Grupo de Riesgo FEMENINO
IV MASCULINO
20-29
FEMENINO
MASCULINO
30-59
FEMENINO
MASCULINO
60 o +
FEMENINO
VI. COMPORTAMIENTO FAMILIAR(F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Violencia intrafamiliar
ACTIVO
Tabaquismo
PASIVO
Maltrato infantil
Consumo excesivo de alcohol
Consumo de drogas
VII. EVALUACIÓN DEL COMPORTAMIENTO FAMILIAR(F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Funcional
Disfuncional
VIII. RESULTADO DE LA EVALUACION DE LA SALUD FAMILIAR(F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Sin problema de salud
Dificultades con los determinantes de salud
Con problema de salud a predominio Dificultades con la salud de los integrantes de la familia
de:
Dificultades en el funcionamiento de la familia

IX. FORMA DE AYUDA FAMILIAR NECESARIA(F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29

Ayuda Educativa
Ayuda Terapéutica
Ayuda Comunitaria
X. ASPECTOS SOCIOCULTURALES (I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Sí
Residencia temporal
No
Sí
Lee No
No Corresponde
Sí 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Escribe No 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
No Corresponde 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Primaria sin concluir
Primaria concluida
Nivel de instrucción Secundaria concluida
Técnico concluido
Universitario concluido
Directivos de gobierno y
empresas 14 o +
Profesionales científicos e
intelectuales
14 o +
Técnicos y profesionales de
nivel medio 14 o +
<14
Empleados de oficina y afines
14 o +
Trabajo de servicios, <14
vendedores y afines 14 o +
Trabajos agrícolas, forestales y <14
afines
14 o +
Artesanos y operarios de <14
oficios 14 o +
Operarios de maquinas e <14
Ocupación instalaciones
 Operarios de maquinas e
Ocupación instalaciones
14 o +
Peones y trabajadores no <14
calificados
14 o +
<14
Fuerzas armadas
14 o +
<14
Sin especificar u otros
14 o +
<14
Estudiante
14 o +
<14
Labores de casa
14 o +

Jubilado o renta dignidad

14 o +

Desempleado
14 o +
Sí
Contribuye a la economía familiar No
No corresponde
XI. MEDICINA TRADICIONAL(I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Siempre
Recurre a la Medicina A veces
Tradicional
Nunca
XII. NACIMIENTOS(I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Masculino
Sexo
Femenino
Dentro Establecimiento
Parto
Fuera Establecimiento
Personal establecimiento
Atendido por Partera
Familiar
Sí
¿Tiene certificación de nacimiento?
No
XIII. DEFUNCIONES (I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Enero
Febrero
Marzo
Abril
Mayo
Junio
Defunciones por mes
Julio
Agosto
Septiembre
Octubre
Noviembre
Diciembre
Institucional
Nro. de Defunciones
No institucional
Neonatal (< 28 días)
Con Certificado de Defunción
Médico
Otorgado por Autoridad
Otro
Sin Certificado de Defunción
XIII. DEFUNCIONES (I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
IRAs
EDAs
Embarazo/ Parto/ Puerperio
Malaria
TB
Corazón
Cáncer
Causa Probable Accidente de Tránsito
Accidente Laboral
Homicidio
Suicidio
Intoxicaciones
Mordedura de Ofidios
Desconoce /No Sabe
Otras
CARPETA FAMILIAR
_________

30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL

0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 5
0 0
0 0
0 0
0 0
0 1
0 0
0 0
0 0
0 0
0 0
0 10
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 15
0 0
0 0
0 0
0 0
0 0
0 0
0 25
0 0
0 2
0 0
0 0
0 0
0 0
0 0
0 3
0 0
0 0
0 5
0 5
0 5
0 0
0 0
0 0
0 0
0 0
0 20
0 0
0 0
0 96
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2
0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0
0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0
0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 9
0 7
0 0
0 2
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 7
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2
0 0
0 5
0 2
0 1
0 0
0
0 0
0
0 0
0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
 0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0
0 0
0
0 0
0 3
0 6
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 3
0 6
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
 INSTRUMENTO DE SISTEMATIZACIÓN ANUAL DE LA CARPETA F
Año: ________________ SEDES__________________ Municipio: _____________________________________ Red de Salud: ______________________________________________
Ambito Geográfico: Urbano Rural Establecimiento: _______________________________________________________
Número de Carpetas Revisadas Comunidad/Localidad/Ciudad/Distrito:
Numeros de Seguimientos de Carpetas Familiares
CARPETAS Completas, Parciales, Bajas
I. DATOS GENERALES (F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
AYMARA
QUECHUA
Hablado CASTELLANO
GUARANI
OTROS
Idiomas
AYMARA
CASTELLANO
Materno QUECHUA
GUARANI
OTROS
<1
1-2
Kilometros
3-4
>4
< 30 minutos
Distancia y tiempo desde la vivienda 30 - 50 minutos
Tiempo a pie
hasta el establecimiento de salud 1 - 2 horas
>2 horas
< 30 minutos
30 - 50 minutos
Tiempo en movilidad
1 - 2 horas
>2 horas
Auxiliar en enfermeria
Cargo del Responsable de llenado Licenciado(a) en enfermeria
Médico(a)
IV. DETERMINANTES DE SALUD (F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
1. Vivienda individual
2. Departamento
A. Tipo de vivienda 3. Cuartos o habitaciones sueltas
4. Choza/Pahuichi/casa rústica
5. Ambiente no destinado para habitar
1. Propia
2. Anticrética
B. Tenencia de 3. Alquiler
Vivienda
4. Cuidador remunerado
5. Otros
1. Una o dos personas
2. Tres
C. No. de personas / 3. Cuatro
cuarto
4. cinco
5. Seis o más
IV. DETERMINANTES DE SALUD (F)
D. Abastecimiento de agua
E. Eliminación de excretas
F. Manejo de Basura
G. Ingreso Familiar
H. Consumo diário de alimentos
I. Nivel de Instrucción de la madre
Rango de riesgo
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
1. Agua por cañería
2. Pileta pública
3. Pozo/Noria/Vertiente/ Cisterna
4. Acequia/río
5.Charcos/ Atajados/Curichi
1. Servicio higiénico en domicilio
2. Servicio higiénico público
3. Letrina
4. Pozo ciego
5. Aire libre
1. Recojo domiciliario
2. Basura enterrada
3. Calle/campo abierto
4. Quemado
5. Río/Quebrada
1. Le permite ahorrar
2. Satisface necesidades
3. Satisface necesidades básicas
4. A veces no alcanza
5. Insuficiente
1. Cons. diario de cereales, tuberculos y derivados
2. Consumo diario de alimentos de origen animal
3. Consumo diario de frutas y verduras
4. Consumo diario de aceite
5. Consumo diario de sal yodada.
1. Universitaria
2. Técnico
3. Secundaria
4. Básica
5. Sin Instrucción
Bajo 28 a 61 puntos
Medio 62 a 126 puntos
Alto 127 a 165 puntos
V. SALUD DE LOS INTEGRANTES DE LA FAMILIA (I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Nro DE INTEGRANTES DE LA FAMILIA
Menores de 5 años 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Mujeres embarazadas
Mayores de 60 años 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Habito de Fumar
Obesidad
Sedentarismo
Factores de Alimentación no adecuada
riesgo
Promiscuidad
Consumo excesivo de alcohol
Consumo de drogas
Problemas de salud
Higiene personal no adecuada
Riesgos laborales
Otros
Tuberculosis(pulmonar y extrapulmonar)
Lepra
Enfermedad de Chagas
Enfermedades VIH / SIDA
Transmisibles
Leishmaniasis
hepatitis
Otras
Neoplasmas malignos
Diabetes mellitus
Hipertensión arterial
Asma
Enfermedades No Cardiopatias(isquèmica, hipertensiva, reumàtica)
Transmisibles Enfermedades del Sistema locomotor(artrosis, artritis)
Enfermedad pulmonar obstructiva crónica
(EPOC)
Insuficiencia renal crónica
Desnutrición crónica
Otras
Intelectual
Fisica
Discapacidad
Sensorial
Multiple

MASCULINO
5-9
FEMENINO
MASCULINO
10-19
FEMENINO
Grupo de Riesgo I
MASCULINO
20-29
FEMENINO
MASCULINO
30-59
FEMENINO
 MASCULINO
<5
FEMENINO
MASCULINO
5-9
FEMENINO
MASCULINO
Problemas de salud 10-19
Grupo de Riesgo FEMENINO
II MASCULINO
20-29
FEMENINO
MASCULINO
30-59
FEMENINO
MASCULINO
60 o +
FEMENINO
MASCULINO
<5
FEMENINO
MASCULINO
5-9
FEMENINO
MASCULINO
10-19
Grupo de Riesgo FEMENINO
III MASCULINO
20-29
FEMENINO
MASCULINO
30-59
FEMENINO
MASCULINO
60 o +
FEMENINO
MASCULINO
<5
FEMENINO
MASCULINO
5-9
FEMENINO
MASCULINO
10-19
Grupo de Riesgo FEMENINO
IV MASCULINO
20-29
FEMENINO
MASCULINO
30-59
FEMENINO
MASCULINO
60 o +
FEMENINO
VI. COMPORTAMIENTO FAMILIAR(F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Violencia intrafamiliar
ACTIVO
Tabaquismo
PASIVO
Maltrato infantil
Consumo excesivo de alcohol
Consumo de drogas
VII. EVALUACIÓN DEL COMPORTAMIENTO FAMILIAR(F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Funcional
Disfuncional
VIII. RESULTADO DE LA EVALUACION DE LA SALUD FAMILIAR(F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Sin problema de salud
Dificultades con los determinantes de salud
Con problema de salud a predominio Dificultades con la salud de los integrantes de la familia
de:
Dificultades en el funcionamiento de la familia

IX. FORMA DE AYUDA FAMILIAR NECESARIA(F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29

Ayuda Educativa
Ayuda Terapéutica
Ayuda Comunitaria
X. ASPECTOS SOCIOCULTURALES (I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Sí
Residencia temporal
No
Sí
Lee No
No Corresponde
Sí 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Escribe No 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
No Corresponde 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Primaria sin concluir
Primaria concluida
Nivel de instrucción Secundaria concluida
Técnico concluido
Universitario concluido
Directivos de gobierno y
empresas 14 o +
Profesionales científicos e
intelectuales
14 o +
Técnicos y profesionales de
nivel medio 14 o +
<14
Empleados de oficina y afines
14 o +
Trabajo de servicios, <14
vendedores y afines 14 o +
Trabajos agrícolas, forestales y <14
afines
14 o +
Artesanos y operarios de <14
oficios 14 o +
Operarios de maquinas e <14
Ocupación instalaciones
 Operarios de maquinas e
Ocupación instalaciones
14 o +
Peones y trabajadores no <14
calificados
14 o +
<14
Fuerzas armadas
14 o +
<14
Sin especificar u otros
14 o +
<14
Estudiante
14 o +
<14
Labores de casa
14 o +

Jubilado o renta dignidad

14 o +

Desempleado
14 o +
Sí
Contribuye a la economía familiar No
No corresponde
XI. MEDICINA TRADICIONAL(I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Siempre
Recurre a la Medicina A veces
Tradicional
Nunca
XII. NACIMIENTOS(I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Masculino
Sexo
Femenino
Dentro Establecimiento
Parto
Fuera Establecimiento
Personal establecimiento
Atendido por Partera
Familiar
Sí
¿Tiene certificación de nacimiento?
No
XIII. DEFUNCIONES (I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Enero
Febrero
Marzo
Abril
Mayo
Junio
Defunciones por mes
Julio
Agosto
Septiembre
Octubre
Noviembre
Diciembre
Institucional
Nro. de Defunciones
No institucional
Neonatal (< 28 días)
Con Certificado de Defunción
Médico
Otorgado por Autoridad
Otro
Sin Certificado de Defunción
XIII. DEFUNCIONES (I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
IRAs
EDAs
Embarazo/ Parto/ Puerperio
Malaria
TB
Corazón
Cáncer
Causa Probable Accidente de Tránsito
Accidente Laboral
Homicidio
Suicidio
Intoxicaciones
Mordedura de Ofidios
Desconoce /No Sabe
Otras
CARPETA FAMILIAR
_________

30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL

0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 5
0 0
0 0
0 0
0 0
0 1
0 0
0 0
0 0
0 0
0 0
0 10
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 15
0 0
0 0
0 0
0 0
0 0
0 0
0 25
0 0
0 2
0 0
0 0
0 0
0 0
0 0
0 3
0 0
0 0
0 5
0 5
0 5
0 0
0 0
0 0
0 0
0 0
0 20
0 0
0 0
0 96
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2
0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0
0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0
0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 9
0 7
0 0
0 2
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 7
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2
0 0
0 5
0 2
0 1
0 0
0
0 0
0
0 0
0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
 0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0
0 0
0
0 0
0 3
0 6
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 3
0 6
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
 INSTRUMENTO DE SISTEMATIZACIÓN ANUAL DE LA CARPETA F
Año: ________________ SEDES__________________ Municipio: _____________________________________ Red de Salud: ______________________________________________
Ambito Geográfico: Urbano Rural Establecimiento: _______________________________________________________
Número de Carpetas Revisadas Comunidad/Localidad/Ciudad/Distrito:
Numeros de Seguimientos de Carpetas Familiares
CARPETAS Completas, Parciales, Bajas
I. DATOS GENERALES (F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
AYMARA
QUECHUA
Hablado CASTELLANO
GUARANI
OTROS
Idiomas
AYMARA
CASTELLANO
Materno QUECHUA
GUARANI
OTROS
<1
1-2
Kilometros
3-4
>4
< 30 minutos
Distancia y tiempo desde la vivienda 30 - 50 minutos
Tiempo a pie
hasta el establecimiento de salud 1 - 2 horas
>2 horas
< 30 minutos
30 - 50 minutos
Tiempo en movilidad
1 - 2 horas
>2 horas
Auxiliar en enfermeria
Cargo del Responsable de llenado Licenciado(a) en enfermeria
Médico(a)
IV. DETERMINANTES DE SALUD (F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
1. Vivienda individual
2. Departamento
A. Tipo de vivienda 3. Cuartos o habitaciones sueltas
4. Choza/Pahuichi/casa rústica
5. Ambiente no destinado para habitar
1. Propia
2. Anticrética
B. Tenencia de 3. Alquiler
Vivienda
4. Cuidador remunerado
5. Otros
1. Una o dos personas
2. Tres
C. No. de personas / 3. Cuatro
cuarto
4. cinco
5. Seis o más
IV. DETERMINANTES DE SALUD (F)
D. Abastecimiento de agua
E. Eliminación de excretas
F. Manejo de Basura
G. Ingreso Familiar
H. Consumo diário de alimentos
I. Nivel de Instrucción de la madre
Rango de riesgo
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
1. Agua por cañería
2. Pileta pública
3. Pozo/Noria/Vertiente/ Cisterna
4. Acequia/río
5.Charcos/ Atajados/Curichi
1. Servicio higiénico en domicilio
2. Servicio higiénico público
3. Letrina
4. Pozo ciego
5. Aire libre
1. Recojo domiciliario
2. Basura enterrada
3. Calle/campo abierto
4. Quemado
5. Río/Quebrada
1. Le permite ahorrar
2. Satisface necesidades
3. Satisface necesidades básicas
4. A veces no alcanza
5. Insuficiente
1. Cons. diario de cereales, tuberculos y derivados
2. Consumo diario de alimentos de origen animal
3. Consumo diario de frutas y verduras
4. Consumo diario de aceite
5. Consumo diario de sal yodada.
1. Universitaria
2. Técnico
3. Secundaria
4. Básica
5. Sin Instrucción
Bajo 28 a 61 puntos
Medio 62 a 126 puntos
Alto 127 a 165 puntos
V. SALUD DE LOS INTEGRANTES DE LA FAMILIA (I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Nro DE INTEGRANTES DE LA FAMILIA
Menores de 5 años 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Mujeres embarazadas
Mayores de 60 años 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Habito de Fumar
Obesidad
Sedentarismo
Factores de Alimentación no adecuada
riesgo
Promiscuidad
Consumo excesivo de alcohol
Consumo de drogas
Problemas de salud
Higiene personal no adecuada
Riesgos laborales
Otros
Tuberculosis(pulmonar y extrapulmonar)
Lepra
Enfermedad de Chagas
Enfermedades VIH / SIDA
Transmisibles
Leishmaniasis
hepatitis
Otras
Neoplasmas malignos
Diabetes mellitus
Hipertensión arterial
Asma
Enfermedades No Cardiopatias(isquèmica, hipertensiva, reumàtica)
Transmisibles Enfermedades del Sistema locomotor(artrosis, artritis)
Enfermedad pulmonar obstructiva crónica
(EPOC)
Insuficiencia renal crónica
Desnutrición crónica
Otras
Intelectual
Fisica
Discapacidad
Sensorial
Multiple

MASCULINO
5-9
FEMENINO
MASCULINO
10-19
FEMENINO
Grupo de Riesgo I
MASCULINO
20-29
FEMENINO
MASCULINO
30-59
FEMENINO
 MASCULINO
<5
FEMENINO
MASCULINO
5-9
FEMENINO
MASCULINO
Problemas de salud 10-19
Grupo de Riesgo FEMENINO
II MASCULINO
20-29
FEMENINO
MASCULINO
30-59
FEMENINO
MASCULINO
60 o +
FEMENINO
MASCULINO
<5
FEMENINO
MASCULINO
5-9
FEMENINO
MASCULINO
10-19
Grupo de Riesgo FEMENINO
III MASCULINO
20-29
FEMENINO
MASCULINO
30-59
FEMENINO
MASCULINO
60 o +
FEMENINO
MASCULINO
<5
FEMENINO
MASCULINO
5-9
FEMENINO
MASCULINO
10-19
Grupo de Riesgo FEMENINO
IV MASCULINO
20-29
FEMENINO
MASCULINO
30-59
FEMENINO
MASCULINO
60 o +
FEMENINO
VI. COMPORTAMIENTO FAMILIAR(F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Violencia intrafamiliar
ACTIVO
Tabaquismo
PASIVO
Maltrato infantil
Consumo excesivo de alcohol
Consumo de drogas
VII. EVALUACIÓN DEL COMPORTAMIENTO FAMILIAR(F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Funcional
Disfuncional
VIII. RESULTADO DE LA EVALUACION DE LA SALUD FAMILIAR(F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Sin problema de salud
Dificultades con los determinantes de salud
Con problema de salud a predominio Dificultades con la salud de los integrantes de la familia
de:
Dificultades en el funcionamiento de la familia

IX. FORMA DE AYUDA FAMILIAR NECESARIA(F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29

Ayuda Educativa
Ayuda Terapéutica
Ayuda Comunitaria
X. ASPECTOS SOCIOCULTURALES (I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Sí
Residencia temporal
No
Sí
Lee No
No Corresponde
Sí 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Escribe No 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
No Corresponde 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Primaria sin concluir
Primaria concluida
Nivel de instrucción Secundaria concluida
Técnico concluido
Universitario concluido
Directivos de gobierno y
empresas 14 o +
Profesionales científicos e
intelectuales
14 o +
Técnicos y profesionales de
nivel medio 14 o +
<14
Empleados de oficina y afines
14 o +
Trabajo de servicios, <14
vendedores y afines 14 o +
Trabajos agrícolas, forestales y <14
afines
14 o +
Artesanos y operarios de <14
oficios 14 o +
Operarios de maquinas e <14
Ocupación instalaciones
 Operarios de maquinas e
Ocupación instalaciones
14 o +
Peones y trabajadores no <14
calificados
14 o +
<14
Fuerzas armadas
14 o +
<14
Sin especificar u otros
14 o +
<14
Estudiante
14 o +
<14
Labores de casa
14 o +

Jubilado o renta dignidad

14 o +

Desempleado
14 o +
Sí
Contribuye a la economía familiar No
No corresponde
XI. MEDICINA TRADICIONAL(I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Siempre
Recurre a la Medicina A veces
Tradicional
Nunca
XII. NACIMIENTOS(I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Masculino
Sexo
Femenino
Dentro Establecimiento
Parto
Fuera Establecimiento
Personal establecimiento
Atendido por Partera
Familiar
Sí
¿Tiene certificación de nacimiento?
No
XIII. DEFUNCIONES (I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Enero
Febrero
Marzo
Abril
Mayo
Junio
Defunciones por mes
Julio
Agosto
Septiembre
Octubre
Noviembre
Diciembre
Institucional
Nro. de Defunciones
No institucional
Neonatal (< 28 días)
Con Certificado de Defunción
Médico
Otorgado por Autoridad
Otro
Sin Certificado de Defunción
XIII. DEFUNCIONES (I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
IRAs
EDAs
Embarazo/ Parto/ Puerperio
Malaria
TB
Corazón
Cáncer
Causa Probable Accidente de Tránsito
Accidente Laboral
Homicidio
Suicidio
Intoxicaciones
Mordedura de Ofidios
Desconoce /No Sabe
Otras
CARPETA FAMILIAR
_________

30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL

0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 5
0 0
0 0
0 0
0 0
0 1
0 0
0 0
0 0
0 0
0 0
0 10
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 15
0 0
0 0
0 0
0 0
0 0
0 0
0 25
0 0
0 2
0 0
0 0
0 0
0 0
0 0
0 3
0 0
0 0
0 5
0 5
0 5
0 0
0 0
0 0
0 0
0 0
0 20
0 0
0 0
0 96
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2
0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0
0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0
0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 9
0 7
0 0
0 2
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 7
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2
0 0
0 5
0 2
0 1
0 0
0
0 0
0
0 0
0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
 0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0
0 0
0
0 0
0 3
0 6
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 3
0 6
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
 INSTRUMENTO DE SISTEMATIZACIÓN ANUAL DE LA CARPETA F
Año: ________________ SEDES__________________ Municipio: _____________________________________ Red de Salud: ______________________________________________
Ambito Geográfico: Urbano Rural Establecimiento: _______________________________________________________
Número de Carpetas Revisadas Comunidad/Localidad/Ciudad/Distrito:
Numeros de Seguimientos de Carpetas Familiares
CARPETAS Completas, Parciales, Bajas
I. DATOS GENERALES (F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
AYMARA
QUECHUA
Hablado CASTELLANO
GUARANI
OTROS
Idiomas
AYMARA
CASTELLANO
Materno QUECHUA
GUARANI
OTROS
<1
1-2
Kilometros
3-4
>4
< 30 minutos
Distancia y tiempo desde la vivienda 30 - 50 minutos
Tiempo a pie
hasta el establecimiento de salud 1 - 2 horas
>2 horas
< 30 minutos
30 - 50 minutos
Tiempo en movilidad
1 - 2 horas
>2 horas
Auxiliar en enfermeria
Cargo del Responsable de llenado Licenciado(a) en enfermeria
Médico(a)
IV. DETERMINANTES DE SALUD (F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
1. Vivienda individual
2. Departamento
A. Tipo de vivienda 3. Cuartos o habitaciones sueltas
4. Choza/Pahuichi/casa rústica
5. Ambiente no destinado para habitar
1. Propia
2. Anticrética
B. Tenencia de 3. Alquiler
Vivienda
4. Cuidador remunerado
5. Otros
1. Una o dos personas
2. Tres
C. No. de personas / 3. Cuatro
cuarto
4. cinco
5. Seis o más
IV. DETERMINANTES DE SALUD (F)
D. Abastecimiento de agua
E. Eliminación de excretas
F. Manejo de Basura
G. Ingreso Familiar
H. Consumo diário de alimentos
I. Nivel de Instrucción de la madre
Rango de riesgo
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
1. Agua por cañería
2. Pileta pública
3. Pozo/Noria/Vertiente/ Cisterna
4. Acequia/río
5.Charcos/ Atajados/Curichi
1. Servicio higiénico en domicilio
2. Servicio higiénico público
3. Letrina
4. Pozo ciego
5. Aire libre
1. Recojo domiciliario
2. Basura enterrada
3. Calle/campo abierto
4. Quemado
5. Río/Quebrada
1. Le permite ahorrar
2. Satisface necesidades
3. Satisface necesidades básicas
4. A veces no alcanza
5. Insuficiente
1. Cons. diario de cereales, tuberculos y derivados
2. Consumo diario de alimentos de origen animal
3. Consumo diario de frutas y verduras
4. Consumo diario de aceite
5. Consumo diario de sal yodada.
1. Universitaria
2. Técnico
3. Secundaria
4. Básica
5. Sin Instrucción
Bajo 28 a 61 puntos
Medio 62 a 126 puntos
Alto 127 a 165 puntos
V. SALUD DE LOS INTEGRANTES DE LA FAMILIA (I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Nro DE INTEGRANTES DE LA FAMILIA
Menores de 5 años 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Mujeres embarazadas
Mayores de 60 años 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Habito de Fumar
Obesidad
Sedentarismo
Factores de Alimentación no adecuada
riesgo
Promiscuidad
Consumo excesivo de alcohol
Consumo de drogas
Problemas de salud
Higiene personal no adecuada
Riesgos laborales
Otros
Tuberculosis(pulmonar y extrapulmonar)
Lepra
Enfermedad de Chagas
Enfermedades VIH / SIDA
Transmisibles
Leishmaniasis
hepatitis
Otras
Neoplasmas malignos
Diabetes mellitus
Hipertensión arterial
Asma
Enfermedades No Cardiopatias(isquèmica, hipertensiva, reumàtica)
Transmisibles Enfermedades del Sistema locomotor(artrosis, artritis)
Enfermedad pulmonar obstructiva crónica
(EPOC)
Insuficiencia renal crónica
Desnutrición crónica
Otras
Intelectual
Fisica
Discapacidad
Sensorial
Multiple

MASCULINO
5-9
FEMENINO
MASCULINO
10-19
FEMENINO
Grupo de Riesgo I
MASCULINO
20-29
FEMENINO
MASCULINO
30-59
FEMENINO
 MASCULINO
<5
FEMENINO
MASCULINO
5-9
FEMENINO
MASCULINO
Problemas de salud 10-19
Grupo de Riesgo FEMENINO
II MASCULINO
20-29
FEMENINO
MASCULINO
30-59
FEMENINO
MASCULINO
60 o +
FEMENINO
MASCULINO
<5
FEMENINO
MASCULINO
5-9
FEMENINO
MASCULINO
10-19
Grupo de Riesgo FEMENINO
III MASCULINO
20-29
FEMENINO
MASCULINO
30-59
FEMENINO
MASCULINO
60 o +
FEMENINO
MASCULINO
<5
FEMENINO
MASCULINO
5-9
FEMENINO
MASCULINO
10-19
Grupo de Riesgo FEMENINO
IV MASCULINO
20-29
FEMENINO
MASCULINO
30-59
FEMENINO
MASCULINO
60 o +
FEMENINO
VI. COMPORTAMIENTO FAMILIAR(F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Violencia intrafamiliar
ACTIVO
Tabaquismo
PASIVO
Maltrato infantil
Consumo excesivo de alcohol
Consumo de drogas
VII. EVALUACIÓN DEL COMPORTAMIENTO FAMILIAR(F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Funcional
Disfuncional
VIII. RESULTADO DE LA EVALUACION DE LA SALUD FAMILIAR(F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Sin problema de salud
Dificultades con los determinantes de salud
Con problema de salud a predominio Dificultades con la salud de los integrantes de la familia
de:
Dificultades en el funcionamiento de la familia

IX. FORMA DE AYUDA FAMILIAR NECESARIA(F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29

Ayuda Educativa
Ayuda Terapéutica
Ayuda Comunitaria
X. ASPECTOS SOCIOCULTURALES (I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Sí
Residencia temporal
No
Sí
Lee No
No Corresponde
Sí 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Escribe No 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
No Corresponde 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Primaria sin concluir
Primaria concluida
Nivel de instrucción Secundaria concluida
Técnico concluido
Universitario concluido
Directivos de gobierno y
empresas 14 o +
Profesionales científicos e
intelectuales
14 o +
Técnicos y profesionales de
nivel medio 14 o +
<14
Empleados de oficina y afines
14 o +
Trabajo de servicios, <14
vendedores y afines 14 o +
Trabajos agrícolas, forestales y <14
afines
14 o +
Artesanos y operarios de <14
oficios 14 o +
Operarios de maquinas e <14
Ocupación instalaciones
 Operarios de maquinas e
Ocupación instalaciones
14 o +
Peones y trabajadores no <14
calificados
14 o +
<14
Fuerzas armadas
14 o +
<14
Sin especificar u otros
14 o +
<14
Estudiante
14 o +
<14
Labores de casa
14 o +

Jubilado o renta dignidad

14 o +

Desempleado
14 o +
Sí
Contribuye a la economía familiar No
No corresponde
XI. MEDICINA TRADICIONAL(I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Siempre
Recurre a la Medicina A veces
Tradicional
Nunca
XII. NACIMIENTOS(I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Masculino
Sexo
Femenino
Dentro Establecimiento
Parto
Fuera Establecimiento
Personal establecimiento
Atendido por Partera
Familiar
Sí
¿Tiene certificación de nacimiento?
No
XIII. DEFUNCIONES (I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Enero
Febrero
Marzo
Abril
Mayo
Junio
Defunciones por mes
Julio
Agosto
Septiembre
Octubre
Noviembre
Diciembre
Institucional
Nro. de Defunciones
No institucional
Neonatal (< 28 días)
Con Certificado de Defunción
Médico
Otorgado por Autoridad
Otro
Sin Certificado de Defunción
XIII. DEFUNCIONES (I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
IRAs
EDAs
Embarazo/ Parto/ Puerperio
Malaria
TB
Corazón
Cáncer
Causa Probable Accidente de Tránsito
Accidente Laboral
Homicidio
Suicidio
Intoxicaciones
Mordedura de Ofidios
Desconoce /No Sabe
Otras
CARPETA FAMILIAR
_________

30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL

0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 5
0 0
0 0
0 0
0 0
0 1
0 0
0 0
0 0
0 0
0 0
0 10
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 15
0 0
0 0
0 0
0 0
0 0
0 0
0 25
0 0
0 2
0 0
0 0
0 0
0 0
0 0
0 3
0 0
0 0
0 5
0 5
0 5
0 0
0 0
0 0
0 0
0 0
0 20
0 0
0 0
0 96
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2
0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0
0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0
0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 9
0 7
0 0
0 2
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 7
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2
0 0
0 5
0 2
0 1
0 0
0
0 0
0
0 0
0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
 0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0
0 0
0
0 0
0 3
0 6
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 3
0 6
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
 INSTRUMENTO DE SISTEMATIZACIÓN ANUAL DE LA CARPETA F
Año: ________________ SEDES__________________ Municipio: _____________________________________ Red de Salud: ______________________________________________
Ambito Geográfico: Urbano Rural Establecimiento: _______________________________________________________
Número de Carpetas Revisadas Comunidad/Localidad/Ciudad/Distrito:
Numeros de Seguimientos de Carpetas Familiares
CARPETAS Completas, Parciales, Bajas
I. DATOS GENERALES (F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
AYMARA
QUECHUA
Hablado CASTELLANO
GUARANI
OTROS
Idiomas
AYMARA
CASTELLANO
Materno QUECHUA
GUARANI
OTROS
<1
1-2
Kilometros
3-4
>4
< 30 minutos
Distancia y tiempo desde la vivienda 30 - 50 minutos
Tiempo a pie
hasta el establecimiento de salud 1 - 2 horas
>2 horas
< 30 minutos
30 - 50 minutos
Tiempo en movilidad
1 - 2 horas
>2 horas
Auxiliar en enfermeria
Cargo del Responsable de llenado Licenciado(a) en enfermeria
Médico(a)
IV. DETERMINANTES DE SALUD (F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
1. Vivienda individual
2. Departamento
A. Tipo de vivienda 3. Cuartos o habitaciones sueltas
4. Choza/Pahuichi/casa rústica
5. Ambiente no destinado para habitar
1. Propia
2. Anticrética
B. Tenencia de 3. Alquiler
Vivienda
4. Cuidador remunerado
5. Otros
1. Una o dos personas
2. Tres
C. No. de personas / 3. Cuatro
cuarto
4. cinco
5. Seis o más
IV. DETERMINANTES DE SALUD (F)
D. Abastecimiento de agua
E. Eliminación de excretas
F. Manejo de Basura
G. Ingreso Familiar
H. Consumo diário de alimentos
I. Nivel de Instrucción de la madre
Rango de riesgo
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
1. Agua por cañería
2. Pileta pública
3. Pozo/Noria/Vertiente/ Cisterna
4. Acequia/río
5.Charcos/ Atajados/Curichi
1. Servicio higiénico en domicilio
2. Servicio higiénico público
3. Letrina
4. Pozo ciego
5. Aire libre
1. Recojo domiciliario
2. Basura enterrada
3. Calle/campo abierto
4. Quemado
5. Río/Quebrada
1. Le permite ahorrar
2. Satisface necesidades
3. Satisface necesidades básicas
4. A veces no alcanza
5. Insuficiente
1. Cons. diario de cereales, tuberculos y derivados
2. Consumo diario de alimentos de origen animal
3. Consumo diario de frutas y verduras
4. Consumo diario de aceite
5. Consumo diario de sal yodada.
1. Universitaria
2. Técnico
3. Secundaria
4. Básica
5. Sin Instrucción
Bajo 28 a 61 puntos
Medio 62 a 126 puntos
Alto 127 a 165 puntos
V. SALUD DE LOS INTEGRANTES DE LA FAMILIA (I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Nro DE INTEGRANTES DE LA FAMILIA
Menores de 5 años 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Mujeres embarazadas
Mayores de 60 años 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Habito de Fumar
Obesidad
Sedentarismo
Factores de Alimentación no adecuada
riesgo
Promiscuidad
Consumo excesivo de alcohol
Consumo de drogas
Problemas de salud
Higiene personal no adecuada
Riesgos laborales
Otros
Tuberculosis(pulmonar y extrapulmonar)
Lepra
Enfermedad de Chagas
Enfermedades VIH / SIDA
Transmisibles
Leishmaniasis
hepatitis
Otras
Neoplasmas malignos
Diabetes mellitus
Hipertensión arterial
Asma
Enfermedades No Cardiopatias(isquèmica, hipertensiva, reumàtica)
Transmisibles Enfermedades del Sistema locomotor(artrosis, artritis)
Enfermedad pulmonar obstructiva crónica
(EPOC)
Insuficiencia renal crónica
Desnutrición crónica
Otras
Intelectual
Fisica
Discapacidad
Sensorial
Multiple

MASCULINO
5-9
FEMENINO
MASCULINO
10-19
FEMENINO
Grupo de Riesgo I
MASCULINO
20-29
FEMENINO
MASCULINO
30-59
FEMENINO
 MASCULINO
<5
FEMENINO
MASCULINO
5-9
FEMENINO
MASCULINO
Problemas de salud 10-19
Grupo de Riesgo FEMENINO
II MASCULINO
20-29
FEMENINO
MASCULINO
30-59
FEMENINO
MASCULINO
60 o +
FEMENINO
MASCULINO
<5
FEMENINO
MASCULINO
5-9
FEMENINO
MASCULINO
10-19
Grupo de Riesgo FEMENINO
III MASCULINO
20-29
FEMENINO
MASCULINO
30-59
FEMENINO
MASCULINO
60 o +
FEMENINO
MASCULINO
<5
FEMENINO
MASCULINO
5-9
FEMENINO
MASCULINO
10-19
Grupo de Riesgo FEMENINO
IV MASCULINO
20-29
FEMENINO
MASCULINO
30-59
FEMENINO
MASCULINO
60 o +
FEMENINO
VI. COMPORTAMIENTO FAMILIAR(F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Violencia intrafamiliar
ACTIVO
Tabaquismo
PASIVO
Maltrato infantil
Consumo excesivo de alcohol
Consumo de drogas
VII. EVALUACIÓN DEL COMPORTAMIENTO FAMILIAR(F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Funcional
Disfuncional
VIII. RESULTADO DE LA EVALUACION DE LA SALUD FAMILIAR(F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Sin problema de salud
Dificultades con los determinantes de salud
Con problema de salud a predominio Dificultades con la salud de los integrantes de la familia
de:
Dificultades en el funcionamiento de la familia

IX. FORMA DE AYUDA FAMILIAR NECESARIA(F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29

Ayuda Educativa
Ayuda Terapéutica
Ayuda Comunitaria
X. ASPECTOS SOCIOCULTURALES (I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Sí
Residencia temporal
No
Sí
Lee No
No Corresponde
Sí 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Escribe No 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
No Corresponde 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Primaria sin concluir
Primaria concluida
Nivel de instrucción Secundaria concluida
Técnico concluido
Universitario concluido
Directivos de gobierno y
empresas 14 o +
Profesionales científicos e
intelectuales
14 o +
Técnicos y profesionales de
nivel medio 14 o +
<14
Empleados de oficina y afines
14 o +
Trabajo de servicios, <14
vendedores y afines 14 o +
Trabajos agrícolas, forestales y <14
afines
14 o +
Artesanos y operarios de <14
oficios 14 o +
Operarios de maquinas e <14
Ocupación instalaciones
 Operarios de maquinas e
Ocupación instalaciones
14 o +
Peones y trabajadores no <14
calificados
14 o +
<14
Fuerzas armadas
14 o +
<14
Sin especificar u otros
14 o +
<14
Estudiante
14 o +
<14
Labores de casa
14 o +

Jubilado o renta dignidad

14 o +

Desempleado
14 o +
Sí
Contribuye a la economía familiar No
No corresponde
XI. MEDICINA TRADICIONAL(I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Siempre
Recurre a la Medicina A veces
Tradicional
Nunca
XII. NACIMIENTOS(I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Masculino
Sexo
Femenino
Dentro Establecimiento
Parto
Fuera Establecimiento
Personal establecimiento
Atendido por Partera
Familiar
Sí
¿Tiene certificación de nacimiento?
No
XIII. DEFUNCIONES (I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Enero
Febrero
Marzo
Abril
Mayo
Junio
Defunciones por mes
Julio
Agosto
Septiembre
Octubre
Noviembre
Diciembre
Institucional
Nro. de Defunciones
No institucional
Neonatal (< 28 días)
Con Certificado de Defunción
Médico
Otorgado por Autoridad
Otro
Sin Certificado de Defunción
XIII. DEFUNCIONES (I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
IRAs
EDAs
Embarazo/ Parto/ Puerperio
Malaria
TB
Corazón
Cáncer
Causa Probable Accidente de Tránsito
Accidente Laboral
Homicidio
Suicidio
Intoxicaciones
Mordedura de Ofidios
Desconoce /No Sabe
Otras
CARPETA FAMILIAR
_________

30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL

0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 5
0 0
0 0
0 0
0 0
0 1
0 0
0 0
0 0
0 0
0 0
0 10
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 15
0 0
0 0
0 0
0 0
0 0
0 0
0 25
0 0
0 2
0 0
0 0
0 0
0 0
0 0
0 3
0 0
0 0
0 5
0 5
0 5
0 0
0 0
0 0
0 0
0 0
0 20
0 0
0 0
0 96
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2
0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0
0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0
0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 9
0 7
0 0
0 2
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 7
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2
0 0
0 5
0 2
0 1
0 0
0
0 0
0
0 0
0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
 0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0
0 0
0
0 0
0 3
0 6
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 3
0 6
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
 INSTRUMENTO DE SISTEMATIZACIÓN ANUAL DE LA CARPETA F
Año: ________________ SEDES__________________ Municipio: _____________________________________ Red de Salud: ______________________________________________
Ambito Geográfico: Urbano Rural Establecimiento: _______________________________________________________
Número de Carpetas Revisadas Comunidad/Localidad/Ciudad/Distrito:
Numeros de Seguimientos de Carpetas Familiares
CARPETAS Completas, Parciales, Bajas
I. DATOS GENERALES (F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
AYMARA
QUECHUA
Hablado CASTELLANO
GUARANI
OTROS
Idiomas
AYMARA
CASTELLANO
Materno QUECHUA
GUARANI
OTROS
<1
1-2
Kilometros
3-4
>4
< 30 minutos
Distancia y tiempo desde la vivienda 30 - 50 minutos
Tiempo a pie
hasta el establecimiento de salud 1 - 2 horas
>2 horas
< 30 minutos
30 - 50 minutos
Tiempo en movilidad
1 - 2 horas
>2 horas
Auxiliar en enfermeria
Cargo del Responsable de llenado Licenciado(a) en enfermeria
Médico(a)
IV. DETERMINANTES DE SALUD (F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
1. Vivienda individual
2. Departamento
A. Tipo de vivienda 3. Cuartos o habitaciones sueltas
4. Choza/Pahuichi/casa rústica
5. Ambiente no destinado para habitar
1. Propia
2. Anticrética
B. Tenencia de 3. Alquiler
Vivienda
4. Cuidador remunerado
5. Otros
1. Una o dos personas
2. Tres
C. No. de personas / 3. Cuatro
cuarto
4. cinco
5. Seis o más
IV. DETERMINANTES DE SALUD (F)
D. Abastecimiento de agua
E. Eliminación de excretas
F. Manejo de Basura
G. Ingreso Familiar
H. Consumo diário de alimentos
I. Nivel de Instrucción de la madre
Rango de riesgo
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
1. Agua por cañería
2. Pileta pública
3. Pozo/Noria/Vertiente/ Cisterna
4. Acequia/río
5.Charcos/ Atajados/Curichi
1. Servicio higiénico en domicilio
2. Servicio higiénico público
3. Letrina
4. Pozo ciego
5. Aire libre
1. Recojo domiciliario
2. Basura enterrada
3. Calle/campo abierto
4. Quemado
5. Río/Quebrada
1. Le permite ahorrar
2. Satisface necesidades
3. Satisface necesidades básicas
4. A veces no alcanza
5. Insuficiente
1. Cons. diario de cereales, tuberculos y derivados
2. Consumo diario de alimentos de origen animal
3. Consumo diario de frutas y verduras
4. Consumo diario de aceite
5. Consumo diario de sal yodada.
1. Universitaria
2. Técnico
3. Secundaria
4. Básica
5. Sin Instrucción
Bajo 28 a 61 puntos
Medio 62 a 126 puntos
Alto 127 a 165 puntos
V. SALUD DE LOS INTEGRANTES DE LA FAMILIA (I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Nro DE INTEGRANTES DE LA FAMILIA
Menores de 5 años 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Mujeres embarazadas
Mayores de 60 años 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Habito de Fumar
Obesidad
Sedentarismo
Factores de Alimentación no adecuada
riesgo
Promiscuidad
Consumo excesivo de alcohol
Consumo de drogas
Problemas de salud
Higiene personal no adecuada
Riesgos laborales
Otros
Tuberculosis(pulmonar y extrapulmonar)
Lepra
Enfermedad de Chagas
Enfermedades VIH / SIDA
Transmisibles
Leishmaniasis
hepatitis
Otras
Neoplasmas malignos
Diabetes mellitus
Hipertensión arterial
Asma
Enfermedades No Cardiopatias(isquèmica, hipertensiva, reumàtica)
Transmisibles Enfermedades del Sistema locomotor(artrosis, artritis)
Enfermedad pulmonar obstructiva crónica
(EPOC)
Insuficiencia renal crónica
Desnutrición crónica
Otras
Intelectual
Fisica
Discapacidad
Sensorial
Multiple

MASCULINO
5-9
FEMENINO
MASCULINO
10-19
FEMENINO
Grupo de Riesgo I
MASCULINO
20-29
FEMENINO
MASCULINO
30-59
FEMENINO
 MASCULINO
<5
FEMENINO
MASCULINO
5-9
FEMENINO
MASCULINO
Problemas de salud 10-19
Grupo de Riesgo FEMENINO
II MASCULINO
20-29
FEMENINO
MASCULINO
30-59
FEMENINO
MASCULINO
60 o +
FEMENINO
MASCULINO
<5
FEMENINO
MASCULINO
5-9
FEMENINO
MASCULINO
10-19
Grupo de Riesgo FEMENINO
III MASCULINO
20-29
FEMENINO
MASCULINO
30-59
FEMENINO
MASCULINO
60 o +
FEMENINO
MASCULINO
<5
FEMENINO
MASCULINO
5-9
FEMENINO
MASCULINO
10-19
Grupo de Riesgo FEMENINO
IV MASCULINO
20-29
FEMENINO
MASCULINO
30-59
FEMENINO
MASCULINO
60 o +
FEMENINO
VI. COMPORTAMIENTO FAMILIAR(F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Violencia intrafamiliar
ACTIVO
Tabaquismo
PASIVO
Maltrato infantil
Consumo excesivo de alcohol
Consumo de drogas
VII. EVALUACIÓN DEL COMPORTAMIENTO FAMILIAR(F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Funcional
Disfuncional
VIII. RESULTADO DE LA EVALUACION DE LA SALUD FAMILIAR(F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Sin problema de salud
Dificultades con los determinantes de salud
Con problema de salud a predominio Dificultades con la salud de los integrantes de la familia
de:
Dificultades en el funcionamiento de la familia

IX. FORMA DE AYUDA FAMILIAR NECESARIA(F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29

Ayuda Educativa
Ayuda Terapéutica
Ayuda Comunitaria
X. ASPECTOS SOCIOCULTURALES (I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Sí
Residencia temporal
No
Sí
Lee No
No Corresponde
Sí 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Escribe No 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
No Corresponde 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Primaria sin concluir
Primaria concluida
Nivel de instrucción Secundaria concluida
Técnico concluido
Universitario concluido
Directivos de gobierno y
empresas 14 o +
Profesionales científicos e
intelectuales
14 o +
Técnicos y profesionales de
nivel medio 14 o +
<14
Empleados de oficina y afines
14 o +
Trabajo de servicios, <14
vendedores y afines 14 o +
Trabajos agrícolas, forestales y <14
afines
14 o +
Artesanos y operarios de <14
oficios 14 o +
Operarios de maquinas e <14
Ocupación instalaciones
 Operarios de maquinas e
Ocupación instalaciones
14 o +
Peones y trabajadores no <14
calificados
14 o +
<14
Fuerzas armadas
14 o +
<14
Sin especificar u otros
14 o +
<14
Estudiante
14 o +
<14
Labores de casa
14 o +

Jubilado o renta dignidad

14 o +

Desempleado
14 o +
Sí
Contribuye a la economía familiar No
No corresponde
XI. MEDICINA TRADICIONAL(I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Siempre
Recurre a la Medicina A veces
Tradicional
Nunca
XII. NACIMIENTOS(I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Masculino
Sexo
Femenino
Dentro Establecimiento
Parto
Fuera Establecimiento
Personal establecimiento
Atendido por Partera
Familiar
Sí
¿Tiene certificación de nacimiento?
No
XIII. DEFUNCIONES (I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Enero
Febrero
Marzo
Abril
Mayo
Junio
Defunciones por mes
Julio
Agosto
Septiembre
Octubre
Noviembre
Diciembre
Institucional
Nro. de Defunciones
No institucional
Neonatal (< 28 días)
Con Certificado de Defunción
Médico
Otorgado por Autoridad
Otro
Sin Certificado de Defunción
XIII. DEFUNCIONES (I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
IRAs
EDAs
Embarazo/ Parto/ Puerperio
Malaria
TB
Corazón
Cáncer
Causa Probable Accidente de Tránsito
Accidente Laboral
Homicidio
Suicidio
Intoxicaciones
Mordedura de Ofidios
Desconoce /No Sabe
Otras
CARPETA FAMILIAR
_________

30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL

0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 5
0 0
0 0
0 0
0 0
0 1
0 0
0 0
0 0
0 0
0 0
0 10
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 15
0 0
0 0
0 0
0 0
0 0
0 0
0 25
0 0
0 2
0 0
0 0
0 0
0 0
0 0
0 3
0 0
0 0
0 5
0 5
0 5
0 0
0 0
0 0
0 0
0 0
0 20
0 0
0 0
0 96
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2
0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0
0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0
0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 9
0 7
0 0
0 2
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 7
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2
0 0
0 5
0 2
0 1
0 0
0
0 0
0
0 0
0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
 0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0
0 0
0
0 0
0 3
0 6
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 3
0 6
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
 INSTRUMENTO DE SISTEMATIZACIÓN ANUAL DE LA CARPETA F
Año: ________________ SEDES__________________ Municipio: _____________________________________ Red de Salud: ______________________________________________
Ambito Geográfico: Urbano Rural Establecimiento: _______________________________________________________
Número de Carpetas Revisadas Comunidad/Localidad/Ciudad/Distrito:
Numeros de Seguimientos de Carpetas Familiares
CARPETAS Completas, Parciales, Bajas
I. DATOS GENERALES (F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
AYMARA
QUECHUA
Hablado CASTELLANO
GUARANI
OTROS
Idiomas
AYMARA
CASTELLANO
Materno QUECHUA
GUARANI
OTROS
<1
1-2
Kilometros
3-4
>4
< 30 minutos
Distancia y tiempo desde la vivienda 30 - 50 minutos
Tiempo a pie
hasta el establecimiento de salud 1 - 2 horas
>2 horas
< 30 minutos
30 - 50 minutos
Tiempo en movilidad
1 - 2 horas
>2 horas
Auxiliar en enfermeria
Cargo del Responsable de llenado Licenciado(a) en enfermeria
Médico(a)
IV. DETERMINANTES DE SALUD (F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
1. Vivienda individual
2. Departamento
A. Tipo de vivienda 3. Cuartos o habitaciones sueltas
4. Choza/Pahuichi/casa rústica
5. Ambiente no destinado para habitar
1. Propia
2. Anticrética
B. Tenencia de 3. Alquiler
Vivienda
4. Cuidador remunerado
5. Otros
1. Una o dos personas
2. Tres
C. No. de personas / 3. Cuatro
cuarto
4. cinco
5. Seis o más
IV. DETERMINANTES DE SALUD (F)
D. Abastecimiento de agua
E. Eliminación de excretas
F. Manejo de Basura
G. Ingreso Familiar
H. Consumo diário de alimentos
I. Nivel de Instrucción de la madre
Rango de riesgo
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
1. Agua por cañería
2. Pileta pública
3. Pozo/Noria/Vertiente/ Cisterna
4. Acequia/río
5.Charcos/ Atajados/Curichi
1. Servicio higiénico en domicilio
2. Servicio higiénico público
3. Letrina
4. Pozo ciego
5. Aire libre
1. Recojo domiciliario
2. Basura enterrada
3. Calle/campo abierto
4. Quemado
5. Río/Quebrada
1. Le permite ahorrar
2. Satisface necesidades
3. Satisface necesidades básicas
4. A veces no alcanza
5. Insuficiente
1. Cons. diario de cereales, tuberculos y derivados
2. Consumo diario de alimentos de origen animal
3. Consumo diario de frutas y verduras
4. Consumo diario de aceite
5. Consumo diario de sal yodada.
1. Universitaria
2. Técnico
3. Secundaria
4. Básica
5. Sin Instrucción
Bajo 28 a 61 puntos
Medio 62 a 126 puntos
Alto 127 a 165 puntos
V. SALUD DE LOS INTEGRANTES DE LA FAMILIA (I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Nro DE INTEGRANTES DE LA FAMILIA
Menores de 5 años 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Mujeres embarazadas
Mayores de 60 años 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Habito de Fumar
Obesidad
Sedentarismo
Factores de Alimentación no adecuada
riesgo
Promiscuidad
Consumo excesivo de alcohol
Consumo de drogas
Problemas de salud
Higiene personal no adecuada
Riesgos laborales
Otros
Tuberculosis(pulmonar y extrapulmonar)
Lepra
Enfermedad de Chagas
Enfermedades VIH / SIDA
Transmisibles
Leishmaniasis
hepatitis
Otras
Neoplasmas malignos
Diabetes mellitus
Hipertensión arterial
Asma
Enfermedades No Cardiopatias(isquèmica, hipertensiva, reumàtica)
Transmisibles Enfermedades del Sistema locomotor(artrosis, artritis)
Enfermedad pulmonar obstructiva crónica
(EPOC)
Insuficiencia renal crónica
Desnutrición crónica
Otras
Intelectual
Fisica
Discapacidad
Sensorial
Multiple

MASCULINO
5-9
FEMENINO
MASCULINO
10-19
FEMENINO
Grupo de Riesgo I
MASCULINO
20-29
FEMENINO
MASCULINO
30-59
FEMENINO
 MASCULINO
<5
FEMENINO
MASCULINO
5-9
FEMENINO
MASCULINO
Problemas de salud 10-19
Grupo de Riesgo FEMENINO
II MASCULINO
20-29
FEMENINO
MASCULINO
30-59
FEMENINO
MASCULINO
60 o +
FEMENINO
MASCULINO
<5
FEMENINO
MASCULINO
5-9
FEMENINO
MASCULINO
10-19
Grupo de Riesgo FEMENINO
III MASCULINO
20-29
FEMENINO
MASCULINO
30-59
FEMENINO
MASCULINO
60 o +
FEMENINO
MASCULINO
<5
FEMENINO
MASCULINO
5-9
FEMENINO
MASCULINO
10-19
Grupo de Riesgo FEMENINO
IV MASCULINO
20-29
FEMENINO
MASCULINO
30-59
FEMENINO
MASCULINO
60 o +
FEMENINO
VI. COMPORTAMIENTO FAMILIAR(F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Violencia intrafamiliar
ACTIVO
Tabaquismo
PASIVO
Maltrato infantil
Consumo excesivo de alcohol
Consumo de drogas
VII. EVALUACIÓN DEL COMPORTAMIENTO FAMILIAR(F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Funcional
Disfuncional
VIII. RESULTADO DE LA EVALUACION DE LA SALUD FAMILIAR(F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Sin problema de salud
Dificultades con los determinantes de salud
Con problema de salud a predominio Dificultades con la salud de los integrantes de la familia
de:
Dificultades en el funcionamiento de la familia

IX. FORMA DE AYUDA FAMILIAR NECESARIA(F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29

Ayuda Educativa
Ayuda Terapéutica
Ayuda Comunitaria
X. ASPECTOS SOCIOCULTURALES (I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Sí
Residencia temporal
No
Sí
Lee No
No Corresponde
Sí 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Escribe No 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
No Corresponde 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Primaria sin concluir
Primaria concluida
Nivel de instrucción Secundaria concluida
Técnico concluido
Universitario concluido
Directivos de gobierno y
empresas 14 o +
Profesionales científicos e
intelectuales
14 o +
Técnicos y profesionales de
nivel medio 14 o +
<14
Empleados de oficina y afines
14 o +
Trabajo de servicios, <14
vendedores y afines 14 o +
Trabajos agrícolas, forestales y <14
afines
14 o +
Artesanos y operarios de <14
oficios 14 o +
Operarios de maquinas e <14
Ocupación instalaciones
 Operarios de maquinas e
Ocupación instalaciones
14 o +
Peones y trabajadores no <14
calificados
14 o +
<14
Fuerzas armadas
14 o +
<14
Sin especificar u otros
14 o +
<14
Estudiante
14 o +
<14
Labores de casa
14 o +

Jubilado o renta dignidad

14 o +

Desempleado
14 o +
Sí
Contribuye a la economía familiar No
No corresponde
XI. MEDICINA TRADICIONAL(I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Siempre
Recurre a la Medicina A veces
Tradicional
Nunca
XII. NACIMIENTOS(I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Masculino
Sexo
Femenino
Dentro Establecimiento
Parto
Fuera Establecimiento
Personal establecimiento
Atendido por Partera
Familiar
Sí
¿Tiene certificación de nacimiento?
No
XIII. DEFUNCIONES (I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Enero
Febrero
Marzo
Abril
Mayo
Junio
Defunciones por mes
Julio
Agosto
Septiembre
Octubre
Noviembre
Diciembre
Institucional
Nro. de Defunciones
No institucional
Neonatal (< 28 días)
Con Certificado de Defunción
Médico
Otorgado por Autoridad
Otro
Sin Certificado de Defunción
XIII. DEFUNCIONES (I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
IRAs
EDAs
Embarazo/ Parto/ Puerperio
Malaria
TB
Corazón
Cáncer
Causa Probable Accidente de Tránsito
Accidente Laboral
Homicidio
Suicidio
Intoxicaciones
Mordedura de Ofidios
Desconoce /No Sabe
Otras
CARPETA FAMILIAR
_________

30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL

0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 5
0 0
0 0
0 0
0 0
0 1
0 0
0 0
0 0
0 0
0 0
0 10
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 15
0 0
0 0
0 0
0 0
0 0
0 0
0 25
0 0
0 2
0 0
0 0
0 0
0 0
0 0
0 3
0 0
0 0
0 5
0 5
0 5
0 0
0 0
0 0
0 0
0 0
0 20
0 0
0 0
0 96
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2
0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0
0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0
0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 9
0 7
0 0
0 2
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 7
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2
0 0
0 5
0 2
0 1
0 0
0
0 0
0
0 0
0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
 0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0
0 0
0
0 0
0 3
0 6
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 3
0 6
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
 INSTRUMENTO DE SISTEMATIZACIÓN ANUAL DE LA CARPETA F
Año: ________________ SEDES__________________ Municipio: _____________________________________ Red de Salud: ______________________________________________
Ambito Geográfico: Urbano Rural Establecimiento: _______________________________________________________
Número de Carpetas Revisadas Comunidad/Localidad/Ciudad/Distrito:
Numeros de Seguimientos de Carpetas Familiares
CARPETAS Completas, Parciales, Bajas
I. DATOS GENERALES (F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
AYMARA
QUECHUA
Hablado CASTELLANO
GUARANI
OTROS
Idiomas
AYMARA
CASTELLANO
Materno QUECHUA
GUARANI
OTROS
<1
1-2
Kilometros
3-4
>4
< 30 minutos
Distancia y tiempo desde la vivienda 30 - 50 minutos
Tiempo a pie
hasta el establecimiento de salud 1 - 2 horas
>2 horas
< 30 minutos
30 - 50 minutos
Tiempo en movilidad
1 - 2 horas
>2 horas
Auxiliar en enfermeria
Cargo del Responsable de llenado Licenciado(a) en enfermeria
Médico(a)
IV. DETERMINANTES DE SALUD (F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
1. Vivienda individual
2. Departamento
A. Tipo de vivienda 3. Cuartos o habitaciones sueltas
4. Choza/Pahuichi/casa rústica
5. Ambiente no destinado para habitar
1. Propia
2. Anticrética
B. Tenencia de 3. Alquiler
Vivienda
4. Cuidador remunerado
5. Otros
1. Una o dos personas
2. Tres
C. No. de personas / 3. Cuatro
cuarto
4. cinco
5. Seis o más
IV. DETERMINANTES DE SALUD (F)
D. Abastecimiento de agua
E. Eliminación de excretas
F. Manejo de Basura
G. Ingreso Familiar
H. Consumo diário de alimentos
I. Nivel de Instrucción de la madre
Rango de riesgo
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
1. Agua por cañería
2. Pileta pública
3. Pozo/Noria/Vertiente/ Cisterna
4. Acequia/río
5.Charcos/ Atajados/Curichi
1. Servicio higiénico en domicilio
2. Servicio higiénico público
3. Letrina
4. Pozo ciego
5. Aire libre
1. Recojo domiciliario
2. Basura enterrada
3. Calle/campo abierto
4. Quemado
5. Río/Quebrada
1. Le permite ahorrar
2. Satisface necesidades
3. Satisface necesidades básicas
4. A veces no alcanza
5. Insuficiente
1. Cons. diario de cereales, tuberculos y derivados
2. Consumo diario de alimentos de origen animal
3. Consumo diario de frutas y verduras
4. Consumo diario de aceite
5. Consumo diario de sal yodada.
1. Universitaria
2. Técnico
3. Secundaria
4. Básica
5. Sin Instrucción
Bajo 28 a 61 puntos
Medio 62 a 126 puntos
Alto 127 a 165 puntos
V. SALUD DE LOS INTEGRANTES DE LA FAMILIA (I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Nro DE INTEGRANTES DE LA FAMILIA
Menores de 5 años 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Mujeres embarazadas
Mayores de 60 años 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Habito de Fumar
Obesidad
Sedentarismo
Factores de Alimentación no adecuada
riesgo
Promiscuidad
Consumo excesivo de alcohol
Consumo de drogas
Problemas de salud
Higiene personal no adecuada
Riesgos laborales
Otros
Tuberculosis(pulmonar y extrapulmonar)
Lepra
Enfermedad de Chagas
Enfermedades VIH / SIDA
Transmisibles
Leishmaniasis
hepatitis
Otras
Neoplasmas malignos
Diabetes mellitus
Hipertensión arterial
Asma
Enfermedades No Cardiopatias(isquèmica, hipertensiva, reumàtica)
Transmisibles Enfermedades del Sistema locomotor(artrosis, artritis)
Enfermedad pulmonar obstructiva crónica
(EPOC)
Insuficiencia renal crónica
Desnutrición crónica
Otras
Intelectual
Fisica
Discapacidad
Sensorial
Multiple

MASCULINO
5-9
FEMENINO
MASCULINO
10-19
FEMENINO
Grupo de Riesgo I
MASCULINO
20-29
FEMENINO
MASCULINO
30-59
FEMENINO
 MASCULINO
<5
FEMENINO
MASCULINO
5-9
FEMENINO
MASCULINO
Problemas de salud 10-19
Grupo de Riesgo FEMENINO
II MASCULINO
20-29
FEMENINO
MASCULINO
30-59
FEMENINO
MASCULINO
60 o +
FEMENINO
MASCULINO
<5
FEMENINO
MASCULINO
5-9
FEMENINO
MASCULINO
10-19
Grupo de Riesgo FEMENINO
III MASCULINO
20-29
FEMENINO
MASCULINO
30-59
FEMENINO
MASCULINO
60 o +
FEMENINO
MASCULINO
<5
FEMENINO
MASCULINO
5-9
FEMENINO
MASCULINO
10-19
Grupo de Riesgo FEMENINO
IV MASCULINO
20-29
FEMENINO
MASCULINO
30-59
FEMENINO
MASCULINO
60 o +
FEMENINO
VI. COMPORTAMIENTO FAMILIAR(F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Violencia intrafamiliar
ACTIVO
Tabaquismo
PASIVO
Maltrato infantil
Consumo excesivo de alcohol
Consumo de drogas
VII. EVALUACIÓN DEL COMPORTAMIENTO FAMILIAR(F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Funcional
Disfuncional
VIII. RESULTADO DE LA EVALUACION DE LA SALUD FAMILIAR(F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Sin problema de salud
Dificultades con los determinantes de salud
Con problema de salud a predominio Dificultades con la salud de los integrantes de la familia
de:
Dificultades en el funcionamiento de la familia

IX. FORMA DE AYUDA FAMILIAR NECESARIA(F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29

Ayuda Educativa
Ayuda Terapéutica
Ayuda Comunitaria
X. ASPECTOS SOCIOCULTURALES (I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Sí
Residencia temporal
No
Sí
Lee No
No Corresponde
Sí 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Escribe No 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
No Corresponde 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Primaria sin concluir
Primaria concluida
Nivel de instrucción Secundaria concluida
Técnico concluido
Universitario concluido
Directivos de gobierno y
empresas 14 o +
Profesionales científicos e
intelectuales
14 o +
Técnicos y profesionales de
nivel medio 14 o +
<14
Empleados de oficina y afines
14 o +
Trabajo de servicios, <14
vendedores y afines 14 o +
Trabajos agrícolas, forestales y <14
afines
14 o +
Artesanos y operarios de <14
oficios 14 o +
Operarios de maquinas e <14
Ocupación instalaciones
 Operarios de maquinas e
Ocupación instalaciones
14 o +
Peones y trabajadores no <14
calificados
14 o +
<14
Fuerzas armadas
14 o +
<14
Sin especificar u otros
14 o +
<14
Estudiante
14 o +
<14
Labores de casa
14 o +

Jubilado o renta dignidad

14 o +

Desempleado
14 o +
Sí
Contribuye a la economía familiar No
No corresponde
XI. MEDICINA TRADICIONAL(I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Siempre
Recurre a la Medicina A veces
Tradicional
Nunca
XII. NACIMIENTOS(I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Masculino
Sexo
Femenino
Dentro Establecimiento
Parto
Fuera Establecimiento
Personal establecimiento
Atendido por Partera
Familiar
Sí
¿Tiene certificación de nacimiento?
No
XIII. DEFUNCIONES (I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Enero
Febrero
Marzo
Abril
Mayo
Junio
Defunciones por mes
Julio
Agosto
Septiembre
Octubre
Noviembre
Diciembre
Institucional
Nro. de Defunciones
No institucional
Neonatal (< 28 días)
Con Certificado de Defunción
Médico
Otorgado por Autoridad
Otro
Sin Certificado de Defunción
XIII. DEFUNCIONES (I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
IRAs
EDAs
Embarazo/ Parto/ Puerperio
Malaria
TB
Corazón
Cáncer
Causa Probable Accidente de Tránsito
Accidente Laboral
Homicidio
Suicidio
Intoxicaciones
Mordedura de Ofidios
Desconoce /No Sabe
Otras
CARPETA FAMILIAR
_________

30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL

0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 5
0 0
0 0
0 0
0 0
0 1
0 0
0 0
0 0
0 0
0 0
0 10
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 15
0 0
0 0
0 0
0 0
0 0
0 0
0 25
0 0
0 2
0 0
0 0
0 0
0 0
0 0
0 3
0 0
0 0
0 5
0 5
0 5
0 0
0 0
0 0
0 0
0 0
0 20
0 0
0 0
0 96
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2
0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0
0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0
0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 9
0 7
0 0
0 2
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 7
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2
0 0
0 5
0 2
0 1
0 0
0
0 0
0
0 0
0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
 0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0
0 0
0
0 0
0 3
0 6
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 3
0 6
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
 INSTRUMENTO DE SISTEMATIZACIÓN ANUAL DE LA CARPETA F
Año: ________________ SEDES__________________ Municipio: _____________________________________ Red de Salud: ______________________________________________
Ambito Geográfico: Urbano Rural Establecimiento: _______________________________________________________
Número de Carpetas Revisadas Comunidad/Localidad/Ciudad/Distrito:
Numeros de Seguimientos de Carpetas Familiares
CARPETAS Completas, Parciales, Bajas
I. DATOS GENERALES (F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
AYMARA
QUECHUA
Hablado CASTELLANO
GUARANI
OTROS
Idiomas
AYMARA
CASTELLANO
Materno QUECHUA
GUARANI
OTROS
<1
1-2
Kilometros
3-4
>4
< 30 minutos
Distancia y tiempo desde la vivienda 30 - 50 minutos
Tiempo a pie
hasta el establecimiento de salud 1 - 2 horas
>2 horas
< 30 minutos
30 - 50 minutos
Tiempo en movilidad
1 - 2 horas
>2 horas
Auxiliar en enfermeria
Cargo del Responsable de llenado Licenciado(a) en enfermeria
Médico(a)
IV. DETERMINANTES DE SALUD (F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
1. Vivienda individual
2. Departamento
A. Tipo de vivienda 3. Cuartos o habitaciones sueltas
4. Choza/Pahuichi/casa rústica
5. Ambiente no destinado para habitar
1. Propia
2. Anticrética
B. Tenencia de 3. Alquiler
Vivienda
4. Cuidador remunerado
5. Otros
1. Una o dos personas
2. Tres
C. No. de personas / 3. Cuatro
cuarto
4. cinco
5. Seis o más
IV. DETERMINANTES DE SALUD (F)
D. Abastecimiento de agua
E. Eliminación de excretas
F. Manejo de Basura
G. Ingreso Familiar
H. Consumo diário de alimentos
I. Nivel de Instrucción de la madre
Rango de riesgo
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
1. Agua por cañería
2. Pileta pública
3. Pozo/Noria/Vertiente/ Cisterna
4. Acequia/río
5.Charcos/ Atajados/Curichi
1. Servicio higiénico en domicilio
2. Servicio higiénico público
3. Letrina
4. Pozo ciego
5. Aire libre
1. Recojo domiciliario
2. Basura enterrada
3. Calle/campo abierto
4. Quemado
5. Río/Quebrada
1. Le permite ahorrar
2. Satisface necesidades
3. Satisface necesidades básicas
4. A veces no alcanza
5. Insuficiente
1. Cons. diario de cereales, tuberculos y derivados
2. Consumo diario de alimentos de origen animal
3. Consumo diario de frutas y verduras
4. Consumo diario de aceite
5. Consumo diario de sal yodada.
1. Universitaria
2. Técnico
3. Secundaria
4. Básica
5. Sin Instrucción
Bajo 28 a 61 puntos
Medio 62 a 126 puntos
Alto 127 a 165 puntos
V. SALUD DE LOS INTEGRANTES DE LA FAMILIA (I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Nro DE INTEGRANTES DE LA FAMILIA
Menores de 5 años 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Mujeres embarazadas
Mayores de 60 años 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Habito de Fumar
Obesidad
Sedentarismo
Factores de Alimentación no adecuada
riesgo
Promiscuidad
Consumo excesivo de alcohol
Consumo de drogas
Problemas de salud
Higiene personal no adecuada
Riesgos laborales
Otros
Tuberculosis(pulmonar y extrapulmonar)
Lepra
Enfermedad de Chagas
Enfermedades VIH / SIDA
Transmisibles
Leishmaniasis
hepatitis
Otras
Neoplasmas malignos
Diabetes mellitus
Hipertensión arterial
Asma
Enfermedades No Cardiopatias(isquèmica, hipertensiva, reumàtica)
Transmisibles Enfermedades del Sistema locomotor(artrosis, artritis)
Enfermedad pulmonar obstructiva crónica
(EPOC)
Insuficiencia renal crónica
Desnutrición crónica
Otras
Intelectual
Fisica
Discapacidad
Sensorial
Multiple

MASCULINO
5-9
FEMENINO
MASCULINO
10-19
FEMENINO
Grupo de Riesgo I
MASCULINO
20-29
FEMENINO
MASCULINO
30-59
FEMENINO
 MASCULINO
<5
FEMENINO
MASCULINO
5-9
FEMENINO
MASCULINO
Problemas de salud 10-19
Grupo de Riesgo FEMENINO
II MASCULINO
20-29
FEMENINO
MASCULINO
30-59
FEMENINO
MASCULINO
60 o +
FEMENINO
MASCULINO
<5
FEMENINO
MASCULINO
5-9
FEMENINO
MASCULINO
10-19
Grupo de Riesgo FEMENINO
III MASCULINO
20-29
FEMENINO
MASCULINO
30-59
FEMENINO
MASCULINO
60 o +
FEMENINO
MASCULINO
<5
FEMENINO
MASCULINO
5-9
FEMENINO
MASCULINO
10-19
Grupo de Riesgo FEMENINO
IV MASCULINO
20-29
FEMENINO
MASCULINO
30-59
FEMENINO
MASCULINO
60 o +
FEMENINO
VI. COMPORTAMIENTO FAMILIAR(F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Violencia intrafamiliar
ACTIVO
Tabaquismo
PASIVO
Maltrato infantil
Consumo excesivo de alcohol
Consumo de drogas
VII. EVALUACIÓN DEL COMPORTAMIENTO FAMILIAR(F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Funcional
Disfuncional
VIII. RESULTADO DE LA EVALUACION DE LA SALUD FAMILIAR(F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Sin problema de salud
Dificultades con los determinantes de salud
Con problema de salud a predominio Dificultades con la salud de los integrantes de la familia
de:
Dificultades en el funcionamiento de la familia

IX. FORMA DE AYUDA FAMILIAR NECESARIA(F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29

Ayuda Educativa
Ayuda Terapéutica
Ayuda Comunitaria
X. ASPECTOS SOCIOCULTURALES (I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Sí
Residencia temporal
No
Sí
Lee No
No Corresponde
Sí 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Escribe No 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
No Corresponde 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Primaria sin concluir
Primaria concluida
Nivel de instrucción Secundaria concluida
Técnico concluido
Universitario concluido
Directivos de gobierno y
empresas 14 o +
Profesionales científicos e
intelectuales
14 o +
Técnicos y profesionales de
nivel medio 14 o +
<14
Empleados de oficina y afines
14 o +
Trabajo de servicios, <14
vendedores y afines 14 o +
Trabajos agrícolas, forestales y <14
afines
14 o +
Artesanos y operarios de <14
oficios 14 o +
Operarios de maquinas e <14
Ocupación instalaciones
 Operarios de maquinas e
Ocupación instalaciones
14 o +
Peones y trabajadores no <14
calificados
14 o +
<14
Fuerzas armadas
14 o +
<14
Sin especificar u otros
14 o +
<14
Estudiante
14 o +
<14
Labores de casa
14 o +

Jubilado o renta dignidad

14 o +

Desempleado
14 o +
Sí
Contribuye a la economía familiar No
No corresponde
XI. MEDICINA TRADICIONAL(I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Siempre
Recurre a la Medicina A veces
Tradicional
Nunca
XII. NACIMIENTOS(I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Masculino
Sexo
Femenino
Dentro Establecimiento
Parto
Fuera Establecimiento
Personal establecimiento
Atendido por Partera
Familiar
Sí
¿Tiene certificación de nacimiento?
No
XIII. DEFUNCIONES (I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Enero
Febrero
Marzo
Abril
Mayo
Junio
Defunciones por mes
Julio
Agosto
Septiembre
Octubre
Noviembre
Diciembre
Institucional
Nro. de Defunciones
No institucional
Neonatal (< 28 días)
Con Certificado de Defunción
Médico
Otorgado por Autoridad
Otro
Sin Certificado de Defunción
XIII. DEFUNCIONES (I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
IRAs
EDAs
Embarazo/ Parto/ Puerperio
Malaria
TB
Corazón
Cáncer
Causa Probable Accidente de Tránsito
Accidente Laboral
Homicidio
Suicidio
Intoxicaciones
Mordedura de Ofidios
Desconoce /No Sabe
Otras
CARPETA FAMILIAR
_________

30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL

0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 5
0 0
0 0
0 0
0 0
0 1
0 0
0 0
0 0
0 0
0 0
0 10
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 15
0 0
0 0
0 0
0 0
0 0
0 0
0 25
0 0
0 2
0 0
0 0
0 0
0 0
0 0
0 3
0 0
0 0
0 5
0 5
0 5
0 0
0 0
0 0
0 0
0 0
0 20
0 0
0 0
0 96
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2
0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0
0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0
0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 9
0 7
0 0
0 2
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 7
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2
0 0
0 5
0 2
0 1
0 0
0
0 0
0
0 0
0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
 0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0
0 0
0
0 0
0 3
0 6
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 3
0 6
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
 INSTRUMENTO DE SISTEMATIZACIÓN ANUAL DE LA CARPETA F
Año: ________________ SEDES__________________ Municipio: _____________________________________ Red de Salud: ______________________________________________
Ambito Geográfico: Urbano Rural Establecimiento: _______________________________________________________
Número de Carpetas Revisadas Comunidad/Localidad/Ciudad/Distrito:
Numeros de Seguimientos de Carpetas Familiares
CARPETAS Completas, Parciales, Bajas
I. DATOS GENERALES (F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
AYMARA
QUECHUA
Hablado CASTELLANO
GUARANI
OTROS
Idiomas
AYMARA
CASTELLANO
Materno QUECHUA
GUARANI
OTROS
<1
1-2
Kilometros
3-4
>4
< 30 minutos
Distancia y tiempo desde la vivienda 30 - 50 minutos
Tiempo a pie
hasta el establecimiento de salud 1 - 2 horas
>2 horas
< 30 minutos
30 - 50 minutos
Tiempo en movilidad
1 - 2 horas
>2 horas
Auxiliar en enfermeria
Cargo del Responsable de llenado Licenciado(a) en enfermeria
Médico(a)
IV. DETERMINANTES DE SALUD (F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
1. Vivienda individual
2. Departamento
A. Tipo de vivienda 3. Cuartos o habitaciones sueltas
4. Choza/Pahuichi/casa rústica
5. Ambiente no destinado para habitar
1. Propia
2. Anticrética
B. Tenencia de 3. Alquiler
Vivienda
4. Cuidador remunerado
5. Otros
1. Una o dos personas
2. Tres
C. No. de personas / 3. Cuatro
cuarto
4. cinco
5. Seis o más
IV. DETERMINANTES DE SALUD (F)
D. Abastecimiento de agua
E. Eliminación de excretas
F. Manejo de Basura
G. Ingreso Familiar
H. Consumo diário de alimentos
I. Nivel de Instrucción de la madre
Rango de riesgo
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
1. Agua por cañería
2. Pileta pública
3. Pozo/Noria/Vertiente/ Cisterna
4. Acequia/río
5.Charcos/ Atajados/Curichi
1. Servicio higiénico en domicilio
2. Servicio higiénico público
3. Letrina
4. Pozo ciego
5. Aire libre
1. Recojo domiciliario
2. Basura enterrada
3. Calle/campo abierto
4. Quemado
5. Río/Quebrada
1. Le permite ahorrar
2. Satisface necesidades
3. Satisface necesidades básicas
4. A veces no alcanza
5. Insuficiente
1. Cons. diario de cereales, tuberculos y derivados
2. Consumo diario de alimentos de origen animal
3. Consumo diario de frutas y verduras
4. Consumo diario de aceite
5. Consumo diario de sal yodada.
1. Universitaria
2. Técnico
3. Secundaria
4. Básica
5. Sin Instrucción
Bajo 28 a 61 puntos
Medio 62 a 126 puntos
Alto 127 a 165 puntos
V. SALUD DE LOS INTEGRANTES DE LA FAMILIA (I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Nro DE INTEGRANTES DE LA FAMILIA
Menores de 5 años 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Mujeres embarazadas
Mayores de 60 años 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Habito de Fumar
Obesidad
Sedentarismo
Factores de Alimentación no adecuada
riesgo
Promiscuidad
Consumo excesivo de alcohol
Consumo de drogas
Problemas de salud
Higiene personal no adecuada
Riesgos laborales
Otros
Tuberculosis(pulmonar y extrapulmonar)
Lepra
Enfermedad de Chagas
Enfermedades VIH / SIDA
Transmisibles
Leishmaniasis
hepatitis
Otras
Neoplasmas malignos
Diabetes mellitus
Hipertensión arterial
Asma
Enfermedades No Cardiopatias(isquèmica, hipertensiva, reumàtica)
Transmisibles Enfermedades del Sistema locomotor(artrosis, artritis)
Enfermedad pulmonar obstructiva crónica
(EPOC)
Insuficiencia renal crónica
Desnutrición crónica
Otras
Intelectual
Fisica
Discapacidad
Sensorial
Multiple

MASCULINO
5-9
FEMENINO
MASCULINO
10-19
FEMENINO
Grupo de Riesgo I
MASCULINO
20-29
FEMENINO
MASCULINO
30-59
FEMENINO
 MASCULINO
<5
FEMENINO
MASCULINO
5-9
FEMENINO
MASCULINO
Problemas de salud 10-19
Grupo de Riesgo FEMENINO
II MASCULINO
20-29
FEMENINO
MASCULINO
30-59
FEMENINO
MASCULINO
60 o +
FEMENINO
MASCULINO
<5
FEMENINO
MASCULINO
5-9
FEMENINO
MASCULINO
10-19
Grupo de Riesgo FEMENINO
III MASCULINO
20-29
FEMENINO
MASCULINO
30-59
FEMENINO
MASCULINO
60 o +
FEMENINO
MASCULINO
<5
FEMENINO
MASCULINO
5-9
FEMENINO
MASCULINO
10-19
Grupo de Riesgo FEMENINO
IV MASCULINO
20-29
FEMENINO
MASCULINO
30-59
FEMENINO
MASCULINO
60 o +
FEMENINO
VI. COMPORTAMIENTO FAMILIAR(F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Violencia intrafamiliar
ACTIVO
Tabaquismo
PASIVO
Maltrato infantil
Consumo excesivo de alcohol
Consumo de drogas
VII. EVALUACIÓN DEL COMPORTAMIENTO FAMILIAR(F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Funcional
Disfuncional
VIII. RESULTADO DE LA EVALUACION DE LA SALUD FAMILIAR(F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Sin problema de salud
Dificultades con los determinantes de salud
Con problema de salud a predominio Dificultades con la salud de los integrantes de la familia
de:
Dificultades en el funcionamiento de la familia

IX. FORMA DE AYUDA FAMILIAR NECESARIA(F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29

Ayuda Educativa
Ayuda Terapéutica
Ayuda Comunitaria
X. ASPECTOS SOCIOCULTURALES (I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Sí
Residencia temporal
No
Sí
Lee No
No Corresponde
Sí 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Escribe No 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
No Corresponde 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Primaria sin concluir
Primaria concluida
Nivel de instrucción Secundaria concluida
Técnico concluido
Universitario concluido
Directivos de gobierno y
empresas 14 o +
Profesionales científicos e
intelectuales
14 o +
Técnicos y profesionales de
nivel medio 14 o +
<14
Empleados de oficina y afines
14 o +
Trabajo de servicios, <14
vendedores y afines 14 o +
Trabajos agrícolas, forestales y <14
afines
14 o +
Artesanos y operarios de <14
oficios 14 o +
Operarios de maquinas e <14
Ocupación instalaciones
 Operarios de maquinas e
Ocupación instalaciones
14 o +
Peones y trabajadores no <14
calificados
14 o +
<14
Fuerzas armadas
14 o +
<14
Sin especificar u otros
14 o +
<14
Estudiante
14 o +
<14
Labores de casa
14 o +

Jubilado o renta dignidad

14 o +

Desempleado
14 o +
Sí
Contribuye a la economía familiar No
No corresponde
XI. MEDICINA TRADICIONAL(I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Siempre
Recurre a la Medicina A veces
Tradicional
Nunca
XII. NACIMIENTOS(I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Masculino
Sexo
Femenino
Dentro Establecimiento
Parto
Fuera Establecimiento
Personal establecimiento
Atendido por Partera
Familiar
Sí
¿Tiene certificación de nacimiento?
No
XIII. DEFUNCIONES (I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Enero
Febrero
Marzo
Abril
Mayo
Junio
Defunciones por mes
Julio
Agosto
Septiembre
Octubre
Noviembre
Diciembre
Institucional
Nro. de Defunciones
No institucional
Neonatal (< 28 días)
Con Certificado de Defunción
Médico
Otorgado por Autoridad
Otro
Sin Certificado de Defunción
XIII. DEFUNCIONES (I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
IRAs
EDAs
Embarazo/ Parto/ Puerperio
Malaria
TB
Corazón
Cáncer
Causa Probable Accidente de Tránsito
Accidente Laboral
Homicidio
Suicidio
Intoxicaciones
Mordedura de Ofidios
Desconoce /No Sabe
Otras
CARPETA FAMILIAR
_________

30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL

0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 5
0 0
0 0
0 0
0 0
0 1
0 0
0 0
0 0
0 0
0 0
0 10
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 15
0 0
0 0
0 0
0 0
0 0
0 0
0 25
0 0
0 2
0 0
0 0
0 0
0 0
0 0
0 3
0 0
0 0
0 5
0 5
0 5
0 0
0 0
0 0
0 0
0 0
0 20
0 0
0 0
0 96
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2
0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0
0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0
0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 9
0 7
0 0
0 2
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 7
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2
0 0
0 5
0 2
0 1
0 0
0
0 0
0
0 0
0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
 0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0
0 0
0
0 0
0 3
0 6
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 3
0 6
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
 INSTRUMENTO DE SISTEMATIZACIÓN ANUAL DE LA CARPETA F
Año: ________________ SEDES__________________ Municipio: _____________________________________ Red de Salud: ______________________________________________
Ambito Geográfico: Urbano Rural Establecimiento: _______________________________________________________
Número de Carpetas Revisadas Comunidad/Localidad/Ciudad/Distrito:
Numeros de Seguimientos de Carpetas Familiares
CARPETAS Completas, Parciales, Bajas
I. DATOS GENERALES (F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
AYMARA
QUECHUA
Hablado CASTELLANO
GUARANI
OTROS
Idiomas
AYMARA
CASTELLANO
Materno QUECHUA
GUARANI
OTROS
<1
1-2
Kilometros
3-4
>4
< 30 minutos
Distancia y tiempo desde la vivienda 30 - 50 minutos
Tiempo a pie
hasta el establecimiento de salud 1 - 2 horas
>2 horas
< 30 minutos
30 - 50 minutos
Tiempo en movilidad
1 - 2 horas
>2 horas
Auxiliar en enfermeria
Cargo del Responsable de llenado Licenciado(a) en enfermeria
Médico(a)
IV. DETERMINANTES DE SALUD (F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
1. Vivienda individual
2. Departamento
A. Tipo de vivienda 3. Cuartos o habitaciones sueltas
4. Choza/Pahuichi/casa rústica
5. Ambiente no destinado para habitar
1. Propia
2. Anticrética
B. Tenencia de 3. Alquiler
Vivienda
4. Cuidador remunerado
5. Otros
1. Una o dos personas
2. Tres
C. No. de personas / 3. Cuatro
cuarto
4. cinco
5. Seis o más
IV. DETERMINANTES DE SALUD (F)
D. Abastecimiento de agua
E. Eliminación de excretas
F. Manejo de Basura
G. Ingreso Familiar
H. Consumo diário de alimentos
I. Nivel de Instrucción de la madre
Rango de riesgo
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
1. Agua por cañería
2. Pileta pública
3. Pozo/Noria/Vertiente/ Cisterna
4. Acequia/río
5.Charcos/ Atajados/Curichi
1. Servicio higiénico en domicilio
2. Servicio higiénico público
3. Letrina
4. Pozo ciego
5. Aire libre
1. Recojo domiciliario
2. Basura enterrada
3. Calle/campo abierto
4. Quemado
5. Río/Quebrada
1. Le permite ahorrar
2. Satisface necesidades
3. Satisface necesidades básicas
4. A veces no alcanza
5. Insuficiente
1. Cons. diario de cereales, tuberculos y derivados
2. Consumo diario de alimentos de origen animal
3. Consumo diario de frutas y verduras
4. Consumo diario de aceite
5. Consumo diario de sal yodada.
1. Universitaria
2. Técnico
3. Secundaria
4. Básica
5. Sin Instrucción
Bajo 28 a 61 puntos
Medio 62 a 126 puntos
Alto 127 a 165 puntos
V. SALUD DE LOS INTEGRANTES DE LA FAMILIA (I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Nro DE INTEGRANTES DE LA FAMILIA
Menores de 5 años 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Mujeres embarazadas
Mayores de 60 años 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Habito de Fumar
Obesidad
Sedentarismo
Factores de Alimentación no adecuada
riesgo
Promiscuidad
Consumo excesivo de alcohol
Consumo de drogas
Problemas de salud
Higiene personal no adecuada
Riesgos laborales
Otros
Tuberculosis(pulmonar y extrapulmonar)
Lepra
Enfermedad de Chagas
Enfermedades VIH / SIDA
Transmisibles
Leishmaniasis
hepatitis
Otras
Neoplasmas malignos
Diabetes mellitus
Hipertensión arterial
Asma
Enfermedades No Cardiopatias(isquèmica, hipertensiva, reumàtica)
Transmisibles Enfermedades del Sistema locomotor(artrosis, artritis)
Enfermedad pulmonar obstructiva crónica
(EPOC)
Insuficiencia renal crónica
Desnutrición crónica
Otras
Intelectual
Fisica
Discapacidad
Sensorial
Multiple

MASCULINO
5-9
FEMENINO
MASCULINO
10-19
FEMENINO
Grupo de Riesgo I
MASCULINO
20-29
FEMENINO
MASCULINO
30-59
FEMENINO
 MASCULINO
<5
FEMENINO
MASCULINO
5-9
FEMENINO
MASCULINO
Problemas de salud 10-19
Grupo de Riesgo FEMENINO
II MASCULINO
20-29
FEMENINO
MASCULINO
30-59
FEMENINO
MASCULINO
60 o +
FEMENINO
MASCULINO
<5
FEMENINO
MASCULINO
5-9
FEMENINO
MASCULINO
10-19
Grupo de Riesgo FEMENINO
III MASCULINO
20-29
FEMENINO
MASCULINO
30-59
FEMENINO
MASCULINO
60 o +
FEMENINO
MASCULINO
<5
FEMENINO
MASCULINO
5-9
FEMENINO
MASCULINO
10-19
Grupo de Riesgo FEMENINO
IV MASCULINO
20-29
FEMENINO
MASCULINO
30-59
FEMENINO
MASCULINO
60 o +
FEMENINO
VI. COMPORTAMIENTO FAMILIAR(F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Violencia intrafamiliar
ACTIVO
Tabaquismo
PASIVO
Maltrato infantil
Consumo excesivo de alcohol
Consumo de drogas
VII. EVALUACIÓN DEL COMPORTAMIENTO FAMILIAR(F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Funcional
Disfuncional
VIII. RESULTADO DE LA EVALUACION DE LA SALUD FAMILIAR(F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Sin problema de salud
Dificultades con los determinantes de salud
Con problema de salud a predominio Dificultades con la salud de los integrantes de la familia
de:
Dificultades en el funcionamiento de la familia

IX. FORMA DE AYUDA FAMILIAR NECESARIA(F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29

Ayuda Educativa
Ayuda Terapéutica
Ayuda Comunitaria
X. ASPECTOS SOCIOCULTURALES (I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Sí
Residencia temporal
No
Sí
Lee No
No Corresponde
Sí 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Escribe No 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
No Corresponde 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Primaria sin concluir
Primaria concluida
Nivel de instrucción Secundaria concluida
Técnico concluido
Universitario concluido
Directivos de gobierno y
empresas 14 o +
Profesionales científicos e
intelectuales
14 o +
Técnicos y profesionales de
nivel medio 14 o +
<14
Empleados de oficina y afines
14 o +
Trabajo de servicios, <14
vendedores y afines 14 o +
Trabajos agrícolas, forestales y <14
afines
14 o +
Artesanos y operarios de <14
oficios 14 o +
Operarios de maquinas e <14
Ocupación instalaciones
 Operarios de maquinas e
Ocupación instalaciones
14 o +
Peones y trabajadores no <14
calificados
14 o +
<14
Fuerzas armadas
14 o +
<14
Sin especificar u otros
14 o +
<14
Estudiante
14 o +
<14
Labores de casa
14 o +

Jubilado o renta dignidad

14 o +

Desempleado
14 o +
Sí
Contribuye a la economía familiar No
No corresponde
XI. MEDICINA TRADICIONAL(I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Siempre
Recurre a la Medicina A veces
Tradicional
Nunca
XII. NACIMIENTOS(I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Masculino
Sexo
Femenino
Dentro Establecimiento
Parto
Fuera Establecimiento
Personal establecimiento
Atendido por Partera
Familiar
Sí
¿Tiene certificación de nacimiento?
No
XIII. DEFUNCIONES (I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Enero
Febrero
Marzo
Abril
Mayo
Junio
Defunciones por mes
Julio
Agosto
Septiembre
Octubre
Noviembre
Diciembre
Institucional
Nro. de Defunciones
No institucional
Neonatal (< 28 días)
Con Certificado de Defunción
Médico
Otorgado por Autoridad
Otro
Sin Certificado de Defunción
XIII. DEFUNCIONES (I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
IRAs
EDAs
Embarazo/ Parto/ Puerperio
Malaria
TB
Corazón
Cáncer
Causa Probable Accidente de Tránsito
Accidente Laboral
Homicidio
Suicidio
Intoxicaciones
Mordedura de Ofidios
Desconoce /No Sabe
Otras
CARPETA FAMILIAR
_________

30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL

0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 5
0 0
0 0
0 0
0 0
0 1
0 0
0 0
0 0
0 0
0 0
0 10
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 15
0 0
0 0
0 0
0 0
0 0
0 0
0 25
0 0
0 2
0 0
0 0
0 0
0 0
0 0
0 3
0 0
0 0
0 5
0 5
0 5
0 0
0 0
0 0
0 0
0 0
0 20
0 0
0 0
0 96
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2
0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0
0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0
0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 9
0 7
0 0
0 2
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 7
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2
0 0
0 5
0 2
0 1
0 0
0
0 0
0
0 0
0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
 0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0
0 0
0
0 0
0 3
0 6
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 3
0 6
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
 INSTRUMENTO DE SISTEMATIZACIÓN ANUAL DE LA CARPETA F
Año: ________________ SEDES__________________ Municipio: _____________________________________ Red de Salud: ______________________________________________
Ambito Geográfico: Urbano Rural Establecimiento: _______________________________________________________
Número de Carpetas Revisadas Comunidad/Localidad/Ciudad/Distrito:
Numeros de Seguimientos de Carpetas Familiares
CARPETAS Completas, Parciales, Bajas
I. DATOS GENERALES (F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
AYMARA
QUECHUA
Hablado CASTELLANO
GUARANI
OTROS
Idiomas
AYMARA
CASTELLANO
Materno QUECHUA
GUARANI
OTROS
<1
1-2
Kilometros
3-4
>4
< 30 minutos
Distancia y tiempo desde la vivienda 30 - 50 minutos
Tiempo a pie
hasta el establecimiento de salud 1 - 2 horas
>2 horas
< 30 minutos
30 - 50 minutos
Tiempo en movilidad
1 - 2 horas
>2 horas
Auxiliar en enfermeria
Cargo del Responsable de llenado Licenciado(a) en enfermeria
Médico(a)
IV. DETERMINANTES DE SALUD (F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
1. Vivienda individual
2. Departamento
A. Tipo de vivienda 3. Cuartos o habitaciones sueltas
4. Choza/Pahuichi/casa rústica
5. Ambiente no destinado para habitar
1. Propia
2. Anticrética
B. Tenencia de 3. Alquiler
Vivienda
4. Cuidador remunerado
5. Otros
1. Una o dos personas
2. Tres
C. No. de personas / 3. Cuatro
cuarto
4. cinco
5. Seis o más
IV. DETERMINANTES DE SALUD (F)
D. Abastecimiento de agua
E. Eliminación de excretas
F. Manejo de Basura
G. Ingreso Familiar
H. Consumo diário de alimentos
I. Nivel de Instrucción de la madre
Rango de riesgo
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
1. Agua por cañería
2. Pileta pública
3. Pozo/Noria/Vertiente/ Cisterna
4. Acequia/río
5.Charcos/ Atajados/Curichi
1. Servicio higiénico en domicilio
2. Servicio higiénico público
3. Letrina
4. Pozo ciego
5. Aire libre
1. Recojo domiciliario
2. Basura enterrada
3. Calle/campo abierto
4. Quemado
5. Río/Quebrada
1. Le permite ahorrar
2. Satisface necesidades
3. Satisface necesidades básicas
4. A veces no alcanza
5. Insuficiente
1. Cons. diario de cereales, tuberculos y derivados
2. Consumo diario de alimentos de origen animal
3. Consumo diario de frutas y verduras
4. Consumo diario de aceite
5. Consumo diario de sal yodada.
1. Universitaria
2. Técnico
3. Secundaria
4. Básica
5. Sin Instrucción
Bajo 28 a 61 puntos
Medio 62 a 126 puntos
Alto 127 a 165 puntos
V. SALUD DE LOS INTEGRANTES DE LA FAMILIA (I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Nro DE INTEGRANTES DE LA FAMILIA
Menores de 5 años 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Mujeres embarazadas
Mayores de 60 años 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Habito de Fumar
Obesidad
Sedentarismo
Factores de Alimentación no adecuada
riesgo
Promiscuidad
Consumo excesivo de alcohol
Consumo de drogas
Problemas de salud
Higiene personal no adecuada
Riesgos laborales
Otros
Tuberculosis(pulmonar y extrapulmonar)
Lepra
Enfermedad de Chagas
Enfermedades VIH / SIDA
Transmisibles
Leishmaniasis
hepatitis
Otras
Neoplasmas malignos
Diabetes mellitus
Hipertensión arterial
Asma
Enfermedades No Cardiopatias(isquèmica, hipertensiva, reumàtica)
Transmisibles Enfermedades del Sistema locomotor(artrosis, artritis)
Enfermedad pulmonar obstructiva crónica
(EPOC)
Insuficiencia renal crónica
Desnutrición crónica
Otras
Intelectual
Fisica
Discapacidad
Sensorial
Multiple

MASCULINO
5-9
FEMENINO
MASCULINO
10-19
FEMENINO
Grupo de Riesgo I
MASCULINO
20-29
FEMENINO
MASCULINO
30-59
FEMENINO
 MASCULINO
<5
FEMENINO
MASCULINO
5-9
FEMENINO
MASCULINO
Problemas de salud 10-19
Grupo de Riesgo FEMENINO
II MASCULINO
20-29
FEMENINO
MASCULINO
30-59
FEMENINO
MASCULINO
60 o +
FEMENINO
MASCULINO
<5
FEMENINO
MASCULINO
5-9
FEMENINO
MASCULINO
10-19
Grupo de Riesgo FEMENINO
III MASCULINO
20-29
FEMENINO
MASCULINO
30-59
FEMENINO
MASCULINO
60 o +
FEMENINO
MASCULINO
<5
FEMENINO
MASCULINO
5-9
FEMENINO
MASCULINO
10-19
Grupo de Riesgo FEMENINO
IV MASCULINO
20-29
FEMENINO
MASCULINO
30-59
FEMENINO
MASCULINO
60 o +
FEMENINO
VI. COMPORTAMIENTO FAMILIAR(F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Violencia intrafamiliar
ACTIVO
Tabaquismo
PASIVO
Maltrato infantil
Consumo excesivo de alcohol
Consumo de drogas
VII. EVALUACIÓN DEL COMPORTAMIENTO FAMILIAR(F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Funcional
Disfuncional
VIII. RESULTADO DE LA EVALUACION DE LA SALUD FAMILIAR(F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Sin problema de salud
Dificultades con los determinantes de salud
Con problema de salud a predominio Dificultades con la salud de los integrantes de la familia
de:
Dificultades en el funcionamiento de la familia

IX. FORMA DE AYUDA FAMILIAR NECESARIA(F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29

Ayuda Educativa
Ayuda Terapéutica
Ayuda Comunitaria
X. ASPECTOS SOCIOCULTURALES (I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Sí
Residencia temporal
No
Sí
Lee No
No Corresponde
Sí 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Escribe No 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
No Corresponde 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Primaria sin concluir
Primaria concluida
Nivel de instrucción Secundaria concluida
Técnico concluido
Universitario concluido
Directivos de gobierno y
empresas 14 o +
Profesionales científicos e
intelectuales
14 o +
Técnicos y profesionales de
nivel medio 14 o +
<14
Empleados de oficina y afines
14 o +
Trabajo de servicios, <14
vendedores y afines 14 o +
Trabajos agrícolas, forestales y <14
afines
14 o +
Artesanos y operarios de <14
oficios 14 o +
Operarios de maquinas e <14
Ocupación instalaciones
 Operarios de maquinas e
Ocupación instalaciones
14 o +
Peones y trabajadores no <14
calificados
14 o +
<14
Fuerzas armadas
14 o +
<14
Sin especificar u otros
14 o +
<14
Estudiante
14 o +
<14
Labores de casa
14 o +

Jubilado o renta dignidad

14 o +

Desempleado
14 o +
Sí
Contribuye a la economía familiar No
No corresponde
XI. MEDICINA TRADICIONAL(I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Siempre
Recurre a la Medicina A veces
Tradicional
Nunca
XII. NACIMIENTOS(I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Masculino
Sexo
Femenino
Dentro Establecimiento
Parto
Fuera Establecimiento
Personal establecimiento
Atendido por Partera
Familiar
Sí
¿Tiene certificación de nacimiento?
No
XIII. DEFUNCIONES (I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Enero
Febrero
Marzo
Abril
Mayo
Junio
Defunciones por mes
Julio
Agosto
Septiembre
Octubre
Noviembre
Diciembre
Institucional
Nro. de Defunciones
No institucional
Neonatal (< 28 días)
Con Certificado de Defunción
Médico
Otorgado por Autoridad
Otro
Sin Certificado de Defunción
XIII. DEFUNCIONES (I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
IRAs
EDAs
Embarazo/ Parto/ Puerperio
Malaria
TB
Corazón
Cáncer
Causa Probable Accidente de Tránsito
Accidente Laboral
Homicidio
Suicidio
Intoxicaciones
Mordedura de Ofidios
Desconoce /No Sabe
Otras
CARPETA FAMILIAR
_________

30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL

0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 5
0 0
0 0
0 0
0 0
0 1
0 0
0 0
0 0
0 0
0 0
0 10
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 15
0 0
0 0
0 0
0 0
0 0
0 0
0 25
0 0
0 2
0 0
0 0
0 0
0 0
0 0
0 3
0 0
0 0
0 5
0 5
0 5
0 0
0 0
0 0
0 0
0 0
0 20
0 0
0 0
0 96
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2
0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0
0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0
0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 9
0 7
0 0
0 2
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 7
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2
0 0
0 5
0 2
0 1
0 0
0
0 0
0
0 0
0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
 0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0
0 0
0
0 0
0 3
0 6
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 3
0 6
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
 INSTRUMENTO DE SISTEMATIZACIÓN ANUAL DE LA CARPETA F
Año: ________________ SEDES__________________ Municipio: _____________________________________ Red de Salud: ______________________________________________
Ambito Geográfico: Urbano Rural Establecimiento: _______________________________________________________
Número de Carpetas Revisadas Comunidad/Localidad/Ciudad/Distrito:
Numeros de Seguimientos de Carpetas Familiares
CARPETAS Completas, Parciales, Bajas
I. DATOS GENERALES (F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
AYMARA
QUECHUA
Hablado CASTELLANO
GUARANI
OTROS
Idiomas
AYMARA
CASTELLANO
Materno QUECHUA
GUARANI
OTROS
<1
1-2
Kilometros
3-4
>4
< 30 minutos
Distancia y tiempo desde la vivienda 30 - 50 minutos
Tiempo a pie
hasta el establecimiento de salud 1 - 2 horas
>2 horas
< 30 minutos
30 - 50 minutos
Tiempo en movilidad
1 - 2 horas
>2 horas
Auxiliar en enfermeria
Cargo del Responsable de llenado Licenciado(a) en enfermeria
Médico(a)
IV. DETERMINANTES DE SALUD (F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
1. Vivienda individual
2. Departamento
A. Tipo de vivienda 3. Cuartos o habitaciones sueltas
4. Choza/Pahuichi/casa rústica
5. Ambiente no destinado para habitar
1. Propia
2. Anticrética
B. Tenencia de 3. Alquiler
Vivienda
4. Cuidador remunerado
5. Otros
1. Una o dos personas
2. Tres
C. No. de personas / 3. Cuatro
cuarto
4. cinco
5. Seis o más
IV. DETERMINANTES DE SALUD (F)
D. Abastecimiento de agua
E. Eliminación de excretas
F. Manejo de Basura
G. Ingreso Familiar
H. Consumo diário de alimentos
I. Nivel de Instrucción de la madre
Rango de riesgo
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
1. Agua por cañería
2. Pileta pública
3. Pozo/Noria/Vertiente/ Cisterna
4. Acequia/río
5.Charcos/ Atajados/Curichi
1. Servicio higiénico en domicilio
2. Servicio higiénico público
3. Letrina
4. Pozo ciego
5. Aire libre
1. Recojo domiciliario
2. Basura enterrada
3. Calle/campo abierto
4. Quemado
5. Río/Quebrada
1. Le permite ahorrar
2. Satisface necesidades
3. Satisface necesidades básicas
4. A veces no alcanza
5. Insuficiente
1. Cons. diario de cereales, tuberculos y derivados
2. Consumo diario de alimentos de origen animal
3. Consumo diario de frutas y verduras
4. Consumo diario de aceite
5. Consumo diario de sal yodada.
1. Universitaria
2. Técnico
3. Secundaria
4. Básica
5. Sin Instrucción
Bajo 28 a 61 puntos
Medio 62 a 126 puntos
Alto 127 a 165 puntos
V. SALUD DE LOS INTEGRANTES DE LA FAMILIA (I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Nro DE INTEGRANTES DE LA FAMILIA
Menores de 5 años 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Mujeres embarazadas
Mayores de 60 años 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Habito de Fumar
Obesidad
Sedentarismo
Factores de Alimentación no adecuada
riesgo
Promiscuidad
Consumo excesivo de alcohol
Consumo de drogas
Problemas de salud
Higiene personal no adecuada
Riesgos laborales
Otros
Tuberculosis(pulmonar y extrapulmonar)
Lepra
Enfermedad de Chagas
Enfermedades VIH / SIDA
Transmisibles
Leishmaniasis
hepatitis
Otras
Neoplasmas malignos
Diabetes mellitus
Hipertensión arterial
Asma
Enfermedades No Cardiopatias(isquèmica, hipertensiva, reumàtica)
Transmisibles Enfermedades del Sistema locomotor(artrosis, artritis)
Enfermedad pulmonar obstructiva crónica
(EPOC)
Insuficiencia renal crónica
Desnutrición crónica
Otras
Intelectual
Fisica
Discapacidad
Sensorial
Multiple

MASCULINO
5-9
FEMENINO
MASCULINO
10-19
FEMENINO
Grupo de Riesgo I
MASCULINO
20-29
FEMENINO
MASCULINO
30-59
FEMENINO
 MASCULINO
<5
FEMENINO
MASCULINO
5-9
FEMENINO
MASCULINO
Problemas de salud 10-19
Grupo de Riesgo FEMENINO
II MASCULINO
20-29
FEMENINO
MASCULINO
30-59
FEMENINO
MASCULINO
60 o +
FEMENINO
MASCULINO
<5
FEMENINO
MASCULINO
5-9
FEMENINO
MASCULINO
10-19
Grupo de Riesgo FEMENINO
III MASCULINO
20-29
FEMENINO
MASCULINO
30-59
FEMENINO
MASCULINO
60 o +
FEMENINO
MASCULINO
<5
FEMENINO
MASCULINO
5-9
FEMENINO
MASCULINO
10-19
Grupo de Riesgo FEMENINO
IV MASCULINO
20-29
FEMENINO
MASCULINO
30-59
FEMENINO
MASCULINO
60 o +
FEMENINO
VI. COMPORTAMIENTO FAMILIAR(F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Violencia intrafamiliar
ACTIVO
Tabaquismo
PASIVO
Maltrato infantil
Consumo excesivo de alcohol
Consumo de drogas
VII. EVALUACIÓN DEL COMPORTAMIENTO FAMILIAR(F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Funcional
Disfuncional
VIII. RESULTADO DE LA EVALUACION DE LA SALUD FAMILIAR(F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Sin problema de salud
Dificultades con los determinantes de salud
Con problema de salud a predominio Dificultades con la salud de los integrantes de la familia
de:
Dificultades en el funcionamiento de la familia

IX. FORMA DE AYUDA FAMILIAR NECESARIA(F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29

Ayuda Educativa
Ayuda Terapéutica
Ayuda Comunitaria
X. ASPECTOS SOCIOCULTURALES (I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Sí
Residencia temporal
No
Sí
Lee No
No Corresponde
Sí 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Escribe No 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
No Corresponde 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Primaria sin concluir
Primaria concluida
Nivel de instrucción Secundaria concluida
Técnico concluido
Universitario concluido
Directivos de gobierno y
empresas 14 o +
Profesionales científicos e
intelectuales
14 o +
Técnicos y profesionales de
nivel medio 14 o +
<14
Empleados de oficina y afines
14 o +
Trabajo de servicios, <14
vendedores y afines 14 o +
Trabajos agrícolas, forestales y <14
afines
14 o +
Artesanos y operarios de <14
oficios 14 o +
Operarios de maquinas e <14
Ocupación instalaciones
 Operarios de maquinas e
Ocupación instalaciones
14 o +
Peones y trabajadores no <14
calificados
14 o +
<14
Fuerzas armadas
14 o +
<14
Sin especificar u otros
14 o +
<14
Estudiante
14 o +
<14
Labores de casa
14 o +

Jubilado o renta dignidad

14 o +

Desempleado
14 o +
Sí
Contribuye a la economía familiar No
No corresponde
XI. MEDICINA TRADICIONAL(I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Siempre
Recurre a la Medicina A veces
Tradicional
Nunca
XII. NACIMIENTOS(I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Masculino
Sexo
Femenino
Dentro Establecimiento
Parto
Fuera Establecimiento
Personal establecimiento
Atendido por Partera
Familiar
Sí
¿Tiene certificación de nacimiento?
No
XIII. DEFUNCIONES (I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Enero
Febrero
Marzo
Abril
Mayo
Junio
Defunciones por mes
Julio
Agosto
Septiembre
Octubre
Noviembre
Diciembre
Institucional
Nro. de Defunciones
No institucional
Neonatal (< 28 días)
Con Certificado de Defunción
Médico
Otorgado por Autoridad
Otro
Sin Certificado de Defunción
XIII. DEFUNCIONES (I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
IRAs
EDAs
Embarazo/ Parto/ Puerperio
Malaria
TB
Corazón
Cáncer
Causa Probable Accidente de Tránsito
Accidente Laboral
Homicidio
Suicidio
Intoxicaciones
Mordedura de Ofidios
Desconoce /No Sabe
Otras
CARPETA FAMILIAR
_________

30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL

0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 5
0 0
0 0
0 0
0 0
0 1
0 0
0 0
0 0
0 0
0 0
0 10
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 15
0 0
0 0
0 0
0 0
0 0
0 0
0 25
0 0
0 2
0 0
0 0
0 0
0 0
0 0
0 3
0 0
0 0
0 5
0 5
0 5
0 0
0 0
0 0
0 0
0 0
0 20
0 0
0 0
0 96
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2
0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0
0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0
0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 9
0 7
0 0
0 2
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 7
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2
0 0
0 5
0 2
0 1
0 0
0
0 0
0
0 0
0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
 0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0
0 0
0
0 0
0 3
0 6
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 3
0 6
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
 INSTRUMENTO DE SISTEMATIZACIÓN ANUAL DE LA CARPETA F
Año: ________________ SEDES__________________ Municipio: _____________________________________ Red de Salud: ______________________________________________
Ambito Geográfico: Urbano Rural Establecimiento: _______________________________________________________
Número de Carpetas Revisadas Comunidad/Localidad/Ciudad/Distrito:
Numeros de Seguimientos de Carpetas Familiares
CARPETAS Completas, Parciales, Bajas
I. DATOS GENERALES (F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
AYMARA
QUECHUA
Hablado CASTELLANO
GUARANI
OTROS
Idiomas
AYMARA
CASTELLANO
Materno QUECHUA
GUARANI
OTROS
<1
1-2
Kilometros
3-4
>4
< 30 minutos
Distancia y tiempo desde la vivienda 30 - 50 minutos
Tiempo a pie
hasta el establecimiento de salud 1 - 2 horas
>2 horas
< 30 minutos
30 - 50 minutos
Tiempo en movilidad
1 - 2 horas
>2 horas
Auxiliar en enfermeria
Cargo del Responsable de llenado Licenciado(a) en enfermeria
Médico(a)
IV. DETERMINANTES DE SALUD (F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
1. Vivienda individual
2. Departamento
A. Tipo de vivienda 3. Cuartos o habitaciones sueltas
4. Choza/Pahuichi/casa rústica
5. Ambiente no destinado para habitar
1. Propia
2. Anticrética
B. Tenencia de 3. Alquiler
Vivienda
4. Cuidador remunerado
5. Otros
1. Una o dos personas
2. Tres
C. No. de personas / 3. Cuatro
cuarto
4. cinco
5. Seis o más
IV. DETERMINANTES DE SALUD (F)
D. Abastecimiento de agua
E. Eliminación de excretas
F. Manejo de Basura
G. Ingreso Familiar
H. Consumo diário de alimentos
I. Nivel de Instrucción de la madre
Rango de riesgo
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
1. Agua por cañería
2. Pileta pública
3. Pozo/Noria/Vertiente/ Cisterna
4. Acequia/río
5.Charcos/ Atajados/Curichi
1. Servicio higiénico en domicilio
2. Servicio higiénico público
3. Letrina
4. Pozo ciego
5. Aire libre
1. Recojo domiciliario
2. Basura enterrada
3. Calle/campo abierto
4. Quemado
5. Río/Quebrada
1. Le permite ahorrar
2. Satisface necesidades
3. Satisface necesidades básicas
4. A veces no alcanza
5. Insuficiente
1. Cons. diario de cereales, tuberculos y derivados
2. Consumo diario de alimentos de origen animal
3. Consumo diario de frutas y verduras
4. Consumo diario de aceite
5. Consumo diario de sal yodada.
1. Universitaria
2. Técnico
3. Secundaria
4. Básica
5. Sin Instrucción
Bajo 28 a 61 puntos
Medio 62 a 126 puntos
Alto 127 a 165 puntos
V. SALUD DE LOS INTEGRANTES DE LA FAMILIA (I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Nro DE INTEGRANTES DE LA FAMILIA
Menores de 5 años 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Mujeres embarazadas
Mayores de 60 años 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Habito de Fumar
Obesidad
Sedentarismo
Factores de Alimentación no adecuada
riesgo
Promiscuidad
Consumo excesivo de alcohol
Consumo de drogas
Problemas de salud
Higiene personal no adecuada
Riesgos laborales
Otros
Tuberculosis(pulmonar y extrapulmonar)
Lepra
Enfermedad de Chagas
Enfermedades VIH / SIDA
Transmisibles
Leishmaniasis
hepatitis
Otras
Neoplasmas malignos
Diabetes mellitus
Hipertensión arterial
Asma
Enfermedades No Cardiopatias(isquèmica, hipertensiva, reumàtica)
Transmisibles Enfermedades del Sistema locomotor(artrosis, artritis)
Enfermedad pulmonar obstructiva crónica
(EPOC)
Insuficiencia renal crónica
Desnutrición crónica
Otras
Intelectual
Fisica
Discapacidad
Sensorial
Multiple

MASCULINO
5-9
FEMENINO
MASCULINO
10-19
FEMENINO
Grupo de Riesgo I
MASCULINO
20-29
FEMENINO
MASCULINO
30-59
FEMENINO
 MASCULINO
<5
FEMENINO
MASCULINO
5-9
FEMENINO
MASCULINO
Problemas de salud 10-19
Grupo de Riesgo FEMENINO
II MASCULINO
20-29
FEMENINO
MASCULINO
30-59
FEMENINO
MASCULINO
60 o +
FEMENINO
MASCULINO
<5
FEMENINO
MASCULINO
5-9
FEMENINO
MASCULINO
10-19
Grupo de Riesgo FEMENINO
III MASCULINO
20-29
FEMENINO
MASCULINO
30-59
FEMENINO
MASCULINO
60 o +
FEMENINO
MASCULINO
<5
FEMENINO
MASCULINO
5-9
FEMENINO
MASCULINO
10-19
Grupo de Riesgo FEMENINO
IV MASCULINO
20-29
FEMENINO
MASCULINO
30-59
FEMENINO
MASCULINO
60 o +
FEMENINO
VI. COMPORTAMIENTO FAMILIAR(F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Violencia intrafamiliar
ACTIVO
Tabaquismo
PASIVO
Maltrato infantil
Consumo excesivo de alcohol
Consumo de drogas
VII. EVALUACIÓN DEL COMPORTAMIENTO FAMILIAR(F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Funcional
Disfuncional
VIII. RESULTADO DE LA EVALUACION DE LA SALUD FAMILIAR(F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Sin problema de salud
Dificultades con los determinantes de salud
Con problema de salud a predominio Dificultades con la salud de los integrantes de la familia
de:
Dificultades en el funcionamiento de la familia

IX. FORMA DE AYUDA FAMILIAR NECESARIA(F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29

Ayuda Educativa
Ayuda Terapéutica
Ayuda Comunitaria
X. ASPECTOS SOCIOCULTURALES (I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Sí
Residencia temporal
No
Sí
Lee No
No Corresponde
Sí 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Escribe No 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
No Corresponde 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Primaria sin concluir
Primaria concluida
Nivel de instrucción Secundaria concluida
Técnico concluido
Universitario concluido
Directivos de gobierno y
empresas 14 o +
Profesionales científicos e
intelectuales
14 o +
Técnicos y profesionales de
nivel medio 14 o +
<14
Empleados de oficina y afines
14 o +
Trabajo de servicios, <14
vendedores y afines 14 o +
Trabajos agrícolas, forestales y <14
afines
14 o +
Artesanos y operarios de <14
oficios 14 o +
Operarios de maquinas e <14
Ocupación instalaciones
 Operarios de maquinas e
Ocupación instalaciones
14 o +
Peones y trabajadores no <14
calificados
14 o +
<14
Fuerzas armadas
14 o +
<14
Sin especificar u otros
14 o +
<14
Estudiante
14 o +
<14
Labores de casa
14 o +

Jubilado o renta dignidad

14 o +

Desempleado
14 o +
Sí
Contribuye a la economía familiar No
No corresponde
XI. MEDICINA TRADICIONAL(I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Siempre
Recurre a la Medicina A veces
Tradicional
Nunca
XII. NACIMIENTOS(I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Masculino
Sexo
Femenino
Dentro Establecimiento
Parto
Fuera Establecimiento
Personal establecimiento
Atendido por Partera
Familiar
Sí
¿Tiene certificación de nacimiento?
No
XIII. DEFUNCIONES (I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Enero
Febrero
Marzo
Abril
Mayo
Junio
Defunciones por mes
Julio
Agosto
Septiembre
Octubre
Noviembre
Diciembre
Institucional
Nro. de Defunciones
No institucional
Neonatal (< 28 días)
Con Certificado de Defunción
Médico
Otorgado por Autoridad
Otro
Sin Certificado de Defunción
XIII. DEFUNCIONES (I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
IRAs
EDAs
Embarazo/ Parto/ Puerperio
Malaria
TB
Corazón
Cáncer
Causa Probable Accidente de Tránsito
Accidente Laboral
Homicidio
Suicidio
Intoxicaciones
Mordedura de Ofidios
Desconoce /No Sabe
Otras
CARPETA FAMILIAR
_________

30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL

0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 5
0 0
0 0
0 0
0 0
0 1
0 0
0 0
0 0
0 0
0 0
0 10
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 15
0 0
0 0
0 0
0 0
0 0
0 0
0 25
0 0
0 2
0 0
0 0
0 0
0 0
0 0
0 3
0 0
0 0
0 5
0 5
0 5
0 0
0 0
0 0
0 0
0 0
0 20
0 0
0 0
0 96
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2
0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0
0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0
0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 9
0 7
0 0
0 2
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 7
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2
0 0
0 5
0 2
0 1
0 0
0
0 0
0
0 0
0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
 0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0
0 0
0
0 0
0 3
0 6
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 3
0 6
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
 INSTRUMENTO DE SISTEMATIZACIÓN ANUAL DE LA CARPETA F
Año: ________________ SEDES__________________ Municipio: _____________________________________ Red de Salud: ______________________________________________
Ambito Geográfico: Urbano Rural Establecimiento: _______________________________________________________
Número de Carpetas Revisadas Comunidad/Localidad/Ciudad/Distrito:
Numeros de Seguimientos de Carpetas Familiares
CARPETAS Completas, Parciales, Bajas
I. DATOS GENERALES (F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
AYMARA
QUECHUA
Hablado CASTELLANO
GUARANI
OTROS
Idiomas
AYMARA
CASTELLANO
Materno QUECHUA
GUARANI
OTROS
<1
1-2
Kilometros
3-4
>4
< 30 minutos
Distancia y tiempo desde la vivienda 30 - 50 minutos
Tiempo a pie
hasta el establecimiento de salud 1 - 2 horas
>2 horas
< 30 minutos
30 - 50 minutos
Tiempo en movilidad
1 - 2 horas
>2 horas
Auxiliar en enfermeria
Cargo del Responsable de llenado Licenciado(a) en enfermeria
Médico(a)
IV. DETERMINANTES DE SALUD (F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
1. Vivienda individual
2. Departamento
A. Tipo de vivienda 3. Cuartos o habitaciones sueltas
4. Choza/Pahuichi/casa rústica
5. Ambiente no destinado para habitar
1. Propia
2. Anticrética
B. Tenencia de 3. Alquiler
Vivienda
4. Cuidador remunerado
5. Otros
1. Una o dos personas
2. Tres
C. No. de personas / 3. Cuatro
cuarto
4. cinco
5. Seis o más
IV. DETERMINANTES DE SALUD (F)
D. Abastecimiento de agua
E. Eliminación de excretas
F. Manejo de Basura
G. Ingreso Familiar
H. Consumo diário de alimentos
I. Nivel de Instrucción de la madre
Rango de riesgo
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
1. Agua por cañería
2. Pileta pública
3. Pozo/Noria/Vertiente/ Cisterna
4. Acequia/río
5.Charcos/ Atajados/Curichi
1. Servicio higiénico en domicilio
2. Servicio higiénico público
3. Letrina
4. Pozo ciego
5. Aire libre
1. Recojo domiciliario
2. Basura enterrada
3. Calle/campo abierto
4. Quemado
5. Río/Quebrada
1. Le permite ahorrar
2. Satisface necesidades
3. Satisface necesidades básicas
4. A veces no alcanza
5. Insuficiente
1. Cons. diario de cereales, tuberculos y derivados
2. Consumo diario de alimentos de origen animal
3. Consumo diario de frutas y verduras
4. Consumo diario de aceite
5. Consumo diario de sal yodada.
1. Universitaria
2. Técnico
3. Secundaria
4. Básica
5. Sin Instrucción
Bajo 28 a 61 puntos
Medio 62 a 126 puntos
Alto 127 a 165 puntos
V. SALUD DE LOS INTEGRANTES DE LA FAMILIA (I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Nro DE INTEGRANTES DE LA FAMILIA
Menores de 5 años 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Mujeres embarazadas
Mayores de 60 años 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Habito de Fumar
Obesidad
Sedentarismo
Factores de Alimentación no adecuada
riesgo
Promiscuidad
Consumo excesivo de alcohol
Consumo de drogas
Problemas de salud
Higiene personal no adecuada
Riesgos laborales
Otros
Tuberculosis(pulmonar y extrapulmonar)
Lepra
Enfermedad de Chagas
Enfermedades VIH / SIDA
Transmisibles
Leishmaniasis
hepatitis
Otras
Neoplasmas malignos
Diabetes mellitus
Hipertensión arterial
Asma
Enfermedades No Cardiopatias(isquèmica, hipertensiva, reumàtica)
Transmisibles Enfermedades del Sistema locomotor(artrosis, artritis)
Enfermedad pulmonar obstructiva crónica
(EPOC)
Insuficiencia renal crónica
Desnutrición crónica
Otras
Intelectual
Fisica
Discapacidad
Sensorial
Multiple

MASCULINO
5-9
FEMENINO
MASCULINO
10-19
FEMENINO
Grupo de Riesgo I
MASCULINO
20-29
FEMENINO
MASCULINO
30-59
FEMENINO
 MASCULINO
<5
FEMENINO
MASCULINO
5-9
FEMENINO
MASCULINO
Problemas de salud 10-19
Grupo de Riesgo FEMENINO
II MASCULINO
20-29
FEMENINO
MASCULINO
30-59
FEMENINO
MASCULINO
60 o +
FEMENINO
MASCULINO
<5
FEMENINO
MASCULINO
5-9
FEMENINO
MASCULINO
10-19
Grupo de Riesgo FEMENINO
III MASCULINO
20-29
FEMENINO
MASCULINO
30-59
FEMENINO
MASCULINO
60 o +
FEMENINO
MASCULINO
<5
FEMENINO
MASCULINO
5-9
FEMENINO
MASCULINO
10-19
Grupo de Riesgo FEMENINO
IV MASCULINO
20-29
FEMENINO
MASCULINO
30-59
FEMENINO
MASCULINO
60 o +
FEMENINO
VI. COMPORTAMIENTO FAMILIAR(F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Violencia intrafamiliar
ACTIVO
Tabaquismo
PASIVO
Maltrato infantil
Consumo excesivo de alcohol
Consumo de drogas
VII. EVALUACIÓN DEL COMPORTAMIENTO FAMILIAR(F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Funcional
Disfuncional
VIII. RESULTADO DE LA EVALUACION DE LA SALUD FAMILIAR(F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Sin problema de salud
Dificultades con los determinantes de salud
Con problema de salud a predominio Dificultades con la salud de los integrantes de la familia
de:
Dificultades en el funcionamiento de la familia

IX. FORMA DE AYUDA FAMILIAR NECESARIA(F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29

Ayuda Educativa
Ayuda Terapéutica
Ayuda Comunitaria
X. ASPECTOS SOCIOCULTURALES (I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Sí
Residencia temporal
No
Sí
Lee No
No Corresponde
Sí 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Escribe No 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
No Corresponde 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Primaria sin concluir
Primaria concluida
Nivel de instrucción Secundaria concluida
Técnico concluido
Universitario concluido
Directivos de gobierno y
empresas 14 o +
Profesionales científicos e
intelectuales
14 o +
Técnicos y profesionales de
nivel medio 14 o +
<14
Empleados de oficina y afines
14 o +
Trabajo de servicios, <14
vendedores y afines 14 o +
Trabajos agrícolas, forestales y <14
afines
14 o +
Artesanos y operarios de <14
oficios 14 o +
Operarios de maquinas e <14
Ocupación instalaciones
 Operarios de maquinas e
Ocupación instalaciones
14 o +
Peones y trabajadores no <14
calificados
14 o +
<14
Fuerzas armadas
14 o +
<14
Sin especificar u otros
14 o +
<14
Estudiante
14 o +
<14
Labores de casa
14 o +

Jubilado o renta dignidad

14 o +

Desempleado
14 o +
Sí
Contribuye a la economía familiar No
No corresponde
XI. MEDICINA TRADICIONAL(I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Siempre
Recurre a la Medicina A veces
Tradicional
Nunca
XII. NACIMIENTOS(I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Masculino
Sexo
Femenino
Dentro Establecimiento
Parto
Fuera Establecimiento
Personal establecimiento
Atendido por Partera
Familiar
Sí
¿Tiene certificación de nacimiento?
No
XIII. DEFUNCIONES (I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Enero
Febrero
Marzo
Abril
Mayo
Junio
Defunciones por mes
Julio
Agosto
Septiembre
Octubre
Noviembre
Diciembre
Institucional
Nro. de Defunciones
No institucional
Neonatal (< 28 días)
Con Certificado de Defunción
Médico
Otorgado por Autoridad
Otro
Sin Certificado de Defunción
XIII. DEFUNCIONES (I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
IRAs
EDAs
Embarazo/ Parto/ Puerperio
Malaria
TB
Corazón
Cáncer
Causa Probable Accidente de Tránsito
Accidente Laboral
Homicidio
Suicidio
Intoxicaciones
Mordedura de Ofidios
Desconoce /No Sabe
Otras
CARPETA FAMILIAR
_________

30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL

0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 5
0 0
0 0
0 0
0 0
0 1
0 0
0 0
0 0
0 0
0 0
0 10
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 15
0 0
0 0
0 0
0 0
0 0
0 0
0 25
0 0
0 2
0 0
0 0
0 0
0 0
0 0
0 3
0 0
0 0
0 5
0 5
0 5
0 0
0 0
0 0
0 0
0 0
0 20
0 0
0 0
0 96
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2
0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0
0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0
0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 9
0 7
0 0
0 2
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 7
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2
0 0
0 5
0 2
0 1
0 0
0
0 0
0
0 0
0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
 0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0
0 0
0
0 0
0 3
0 6
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 3
0 6
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
 INSTRUMENTO DE SISTEMATIZACIÓN ANUAL DE LA CARPETA F
Año: ________________ SEDES__________________ Municipio: _____________________________________ Red de Salud: ______________________________________________
Ambito Geográfico: Urbano Rural Establecimiento: _______________________________________________________
Número de Carpetas Revisadas Comunidad/Localidad/Ciudad/Distrito:
Numeros de Seguimientos de Carpetas Familiares
CARPETAS Completas, Parciales, Bajas
I. DATOS GENERALES (F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
AYMARA
QUECHUA
Hablado CASTELLANO
GUARANI
OTROS
Idiomas
AYMARA
CASTELLANO
Materno QUECHUA
GUARANI
OTROS
<1
1-2
Kilometros
3-4
>4
< 30 minutos
Distancia y tiempo desde la vivienda 30 - 50 minutos
Tiempo a pie
hasta el establecimiento de salud 1 - 2 horas
>2 horas
< 30 minutos
30 - 50 minutos
Tiempo en movilidad
1 - 2 horas
>2 horas
Auxiliar en enfermeria
Cargo del Responsable de llenado Licenciado(a) en enfermeria
Médico(a)
IV. DETERMINANTES DE SALUD (F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
1. Vivienda individual
2. Departamento
A. Tipo de vivienda 3. Cuartos o habitaciones sueltas
4. Choza/Pahuichi/casa rústica
5. Ambiente no destinado para habitar
1. Propia
2. Anticrética
B. Tenencia de 3. Alquiler
Vivienda
4. Cuidador remunerado
5. Otros
1. Una o dos personas
2. Tres
C. No. de personas / 3. Cuatro
cuarto
4. cinco
5. Seis o más
IV. DETERMINANTES DE SALUD (F)
D. Abastecimiento de agua
E. Eliminación de excretas
F. Manejo de Basura
G. Ingreso Familiar
H. Consumo diário de alimentos
I. Nivel de Instrucción de la madre
Rango de riesgo
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
1. Agua por cañería
2. Pileta pública
3. Pozo/Noria/Vertiente/ Cisterna
4. Acequia/río
5.Charcos/ Atajados/Curichi
1. Servicio higiénico en domicilio
2. Servicio higiénico público
3. Letrina
4. Pozo ciego
5. Aire libre
1. Recojo domiciliario
2. Basura enterrada
3. Calle/campo abierto
4. Quemado
5. Río/Quebrada
1. Le permite ahorrar
2. Satisface necesidades
3. Satisface necesidades básicas
4. A veces no alcanza
5. Insuficiente
1. Cons. diario de cereales, tuberculos y derivados
2. Consumo diario de alimentos de origen animal
3. Consumo diario de frutas y verduras
4. Consumo diario de aceite
5. Consumo diario de sal yodada.
1. Universitaria
2. Técnico
3. Secundaria
4. Básica
5. Sin Instrucción
Bajo 28 a 61 puntos
Medio 62 a 126 puntos
Alto 127 a 165 puntos
V. SALUD DE LOS INTEGRANTES DE LA FAMILIA (I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Nro DE INTEGRANTES DE LA FAMILIA
Menores de 5 años 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Mujeres embarazadas
Mayores de 60 años 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Habito de Fumar
Obesidad
Sedentarismo
Factores de Alimentación no adecuada
riesgo
Promiscuidad
Consumo excesivo de alcohol
Consumo de drogas
Problemas de salud
Higiene personal no adecuada
Riesgos laborales
Otros
Tuberculosis(pulmonar y extrapulmonar)
Lepra
Enfermedad de Chagas
Enfermedades VIH / SIDA
Transmisibles
Leishmaniasis
hepatitis
Otras
Neoplasmas malignos
Diabetes mellitus
Hipertensión arterial
Asma
Enfermedades No Cardiopatias(isquèmica, hipertensiva, reumàtica)
Transmisibles Enfermedades del Sistema locomotor(artrosis, artritis)
Enfermedad pulmonar obstructiva crónica
(EPOC)
Insuficiencia renal crónica
Desnutrición crónica
Otras
Intelectual
Fisica
Discapacidad
Sensorial
Multiple

MASCULINO
5-9
FEMENINO
MASCULINO
10-19
FEMENINO
Grupo de Riesgo I
MASCULINO
20-29
FEMENINO
MASCULINO
30-59
FEMENINO
 MASCULINO
<5
FEMENINO
MASCULINO
5-9
FEMENINO
MASCULINO
Problemas de salud 10-19
Grupo de Riesgo FEMENINO
II MASCULINO
20-29
FEMENINO
MASCULINO
30-59
FEMENINO
MASCULINO
60 o +
FEMENINO
MASCULINO
<5
FEMENINO
MASCULINO
5-9
FEMENINO
MASCULINO
10-19
Grupo de Riesgo FEMENINO
III MASCULINO
20-29
FEMENINO
MASCULINO
30-59
FEMENINO
MASCULINO
60 o +
FEMENINO
MASCULINO
<5
FEMENINO
MASCULINO
5-9
FEMENINO
MASCULINO
10-19
Grupo de Riesgo FEMENINO
IV MASCULINO
20-29
FEMENINO
MASCULINO
30-59
FEMENINO
MASCULINO
60 o +
FEMENINO
VI. COMPORTAMIENTO FAMILIAR(F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Violencia intrafamiliar
ACTIVO
Tabaquismo
PASIVO
Maltrato infantil
Consumo excesivo de alcohol
Consumo de drogas
VII. EVALUACIÓN DEL COMPORTAMIENTO FAMILIAR(F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Funcional
Disfuncional
VIII. RESULTADO DE LA EVALUACION DE LA SALUD FAMILIAR(F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Sin problema de salud
Dificultades con los determinantes de salud
Con problema de salud a predominio Dificultades con la salud de los integrantes de la familia
de:
Dificultades en el funcionamiento de la familia

IX. FORMA DE AYUDA FAMILIAR NECESARIA(F) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29

Ayuda Educativa
Ayuda Terapéutica
Ayuda Comunitaria
X. ASPECTOS SOCIOCULTURALES (I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Sí
Residencia temporal
No
Sí
Lee No
No Corresponde
Sí 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Escribe No 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
No Corresponde 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Primaria sin concluir
Primaria concluida
Nivel de instrucción Secundaria concluida
Técnico concluido
Universitario concluido
Directivos de gobierno y
empresas 14 o +
Profesionales científicos e
intelectuales
14 o +
Técnicos y profesionales de
nivel medio 14 o +
<14
Empleados de oficina y afines
14 o +
Trabajo de servicios, <14
vendedores y afines 14 o +
Trabajos agrícolas, forestales y <14
afines
14 o +
Artesanos y operarios de <14
oficios 14 o +
Operarios de maquinas e <14
Ocupación instalaciones
 Operarios de maquinas e
Ocupación instalaciones
14 o +
Peones y trabajadores no <14
calificados
14 o +
<14
Fuerzas armadas
14 o +
<14
Sin especificar u otros
14 o +
<14
Estudiante
14 o +
<14
Labores de casa
14 o +

Jubilado o renta dignidad

14 o +

Desempleado
14 o +
Sí
Contribuye a la economía familiar No
No corresponde
XI. MEDICINA TRADICIONAL(I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Siempre
Recurre a la Medicina A veces
Tradicional
Nunca
XII. NACIMIENTOS(I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Masculino
Sexo
Femenino
Dentro Establecimiento
Parto
Fuera Establecimiento
Personal establecimiento
Atendido por Partera
Familiar
Sí
¿Tiene certificación de nacimiento?
No
XIII. DEFUNCIONES (I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Enero
Febrero
Marzo
Abril
Mayo
Junio
Defunciones por mes
Julio
Agosto
Septiembre
Octubre
Noviembre
Diciembre
Institucional
Nro. de Defunciones
No institucional
Neonatal (< 28 días)
Con Certificado de Defunción
Médico
Otorgado por Autoridad
Otro
Sin Certificado de Defunción
XIII. DEFUNCIONES (I) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
IRAs
EDAs
Embarazo/ Parto/ Puerperio
Malaria
TB
Corazón
Cáncer
Causa Probable Accidente de Tránsito
Accidente Laboral
Homicidio
Suicidio
Intoxicaciones
Mordedura de Ofidios
Desconoce /No Sabe
Otras
CARPETA FAMILIAR
_________

30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL

0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 5
0 0
0 0
0 0
0 0
0 1
0 0
0 0
0 0
0 0
0 0
0 10
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 15
0 0
0 0
0 0
0 0
0 0
0 0
0 25
0 0
0 2
0 0
0 0
0 0
0 0
0 0
0 3
0 0
0 0
0 5
0 5
0 5
0 0
0 0
0 0
0 0
0 0
0 20
0 0
0 0
0 96
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2
0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0
0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0
0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 9
0 7
0 0
0 2
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 7
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2
0 0
0 5
0 2
0 1
0 0
0
0 0
0
0 0
0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
 0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0
0 0
0
0 0
0 3
0 6
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 3
0 6
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 SUB TOTAL TOTAL
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0