MEDICAL( ( Dental( ( MEDICAL( ( Dental( (
(Medico)( ( (Dentista)( (Medico)( ( (Dentista)(
Village( ( Date( ( Village( ( Date( (
(Pueblo)( ( (Fecha)( ( (Pueblo)( ( (Fecha)( (
Name( ( Name( (
(Nombre(y(Apellidos)(((((((((((((( (First(Name(And(Both(Last(Names)( (Nombre(y(Apellidos)(((((((((((((( (First(Name(And(Both(Last(Names)(
Age( ( Male/Female( Pregnant( ( Weight( ( Age( ( Male/Female( Pregnant( ( Weight( (
(Edad)( ( (Hombre/Mujer)( (Embarazada)( ( (Pesos(–(Solo(por(Niños)( ( (Edad)( ( (Hombre/Mujer)( (Embarazada)( ( (Pesos(–(Solo(por(Niños)( (
!
!
Vital(Signs( ( Fever(Last(3(Days?( ( ( Vital(Signs( ( Fever(Last(3(Days?( ( (
(Signos(Vitales)( ( (Fiebre(en(las(3(Días(pasada?)( ( (Signos(Vitales)( ( (Fiebre(en(las(3(Días(pasada?)( (
History( ( (History( (
(Historia)( (Historia)(
Allergies( ( Allergies( (
(Alergias)( ( (Alergias)( (
(
(
Complaint( ( ( ( ( ( Treatment( Complaint( ( ( ( ( ( Treatment(
(Problema)( ( ( ( ( ( (Tratamiento)( (Problema)( ( ( ( ( ( (Tratamiento)(
1.( ( 1.( (
2.( ( 2.( (
3.( ( 3.( (
4.( ( 4.( (
5.( ( 5.( (
Notes:( Notes:(
(Notas)( (Notas)(
( ( ( (
( ( ( (
Albendazole( ( ( ( ((Family(Members(Treated( ( ( Albendazole( ( ( ( ((Family(Members(Treated( ( (
(( ( ( (((((((((((((((Cuantas(personas(en(la(familia(reciben(Mabendazole/Albendazole?)( (( ( ( (((((((((((((((Cuantas(personas(en(la(familia(reciben(Mabendazole/Albendazole?)(
Referred(to(Higher(Level(of(Care:(Y/N( Referred(to(Higher(Level(of(Care:(Y/N(
(mayor(nivel(de(atención)( (mayor(nivel(de(atención)(