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Medical History

Weight Loss Clinic / Clínica de Control de Peso

Cédula Profesional: 8428907

P.º del Centenario 9580, Piso 25, TIJ, B.C. 22010

DateFecha

No patient linkedPatient Medical History

Select Patient

Patient

Patient InformationInformación del Paciente

Patient's Full NameNombre completo del paciente

Date of BirthFecha de nacimiento

AgeEdad

GenderGénero

BMIIMC

WeightPeso

HeightEstatura

General HealthSalud General

Your general health is very important to us. Please answer the following questions carefully.

General HealthEstado general de salud

Medical AllergiesAlergias médicas

Current Medications & SupplementsMedicamentos y suplementos actuales

Medical ConditionsCondiciones Médicas

Do you suffer from any of the following?

Check every condition that applies.

AnemiaHeart ProblemsHeart AttackIrregular HeartbeatHigh Blood PressureChest Pain / AnginaAbnormal EKGRheumatic Heart DiseaseLung ProblemsShortness of BreathAsthmaBronchitisEmphysemaLiver ProblemsHepatitisHIVDiabetesVaricose VeinsPsychiatric TreatmentCortisone TreatmentEye ProblemsKidney ProblemsOther

CancerIf applicable, specify

Family History of Heart DiseaseIf applicable, specify

Lifestyle & Substance UseEstilo de Vida

Drink Alcoholic Beverages?¿Consume bebidas alcohólicas?Check if Yes

Do You Smoke?¿Fuma?Check if Yes

Use Illicit Drugs?¿Usa drogas ilícitas?Check if Yes

Exercise Regularly?¿Hace ejercicio regularmente?Check if Yes

Hospitalization & SurgeryHospitalizaciones y Cirugías

Have you ever been hospitalized?

¿Ha sido hospitalizado?

YesNo

Recent Serious IllnessEnfermedad Grave Reciente

Have you been seriously ill in the past year?

¿Ha tenido una enfermedad grave durante el último año?

YesNo