Injury/Illness Initial Visit

Injury/Illness Initial Visit
Employer (Empleador): ________________________________________
Date (Fecha): ___________
Patient Name (Nombre): _______________________
Address (Dirección): ___________________________ Age (Edad):_________
______________________________________________
SS#:
Chief Complaint: (¿Que lo trae a
la clinica hoy?)
Clear Checks
Medical History (Historia Medica)
Any previous serious medical problems?
(¿Tiene algun problema medico?)
Any previous major surgeries?
Last Tetanus Injection (¿Ultima vacuna del
tétano?)
Family History (Historia Famlilar)
Any Major Family Medical Problems?
(¿De qué enfermedades padece o padecía
su familila?)___________________________
Medications (Medicamentos)
Currently taking any medications (¿Esta
tomado alguna medicina?)
If so please list:
(Escriba los nombre
de su medicina:)
Yes
(Sí)
No
(No)
Yes No
Review Of Systems
Have you had fever, chills or night sweats in the past
month? (Ha sufrido de fiebre or escalofríos de noche en
los meses anterior?) _______________________________
Do you bruise easily? (¿Le salen morados fácil ? )______
Have you had frequent ear infections? (¿Ha tenido
frecuente infección de oído?)________________________
Have you been told that you have a hearing loss? (¿Le
an dicho que tiene pérdida de oír ?)__________________
Have you had any drainage from your ears? (¿Ha
tenido drenaje de los oidos?)________________________
Do you have frequent sinus infections?(¿Tiene sinusitis
frecuente?)________________________________________
Do you have cataracts or glaucoma? (¿Tiene cataratas o
glaucoma?)_______________________________________
Do you have any stomach pain (Tiene dolor de
estomago?________________________________________
Do you have pain when urinating? (¿Tiene dolor
cuando orina?_____________________________________
Have you been told that you have a bleeding problem?
(¿Padece de problemas de la sangre?)____________
Social History (Historia Social)
Do you smoke ? (¿Fuma?)
Do you drink alcohol ? (¿Bebe alcohol?)
Allergies (Alergias)
Please list below any allergies you
have( Escriba que alergias tiene):
_____________________________________
_____________________________________
_____________________________________
Have you had any shortness of breath? (¿Ha senido que
esta falta de aire?__________________________________
Have you had chest pain (¿Tiene dolor en el pecho?)___
Are you being treated for high blood pressure or heart
problems? (¿Esta bajo tratamiento para alta presión?)___
Have you had phlebitis or blood clots in the veins of
your legs? (¿Padece de flebitis o coágulo de sangre en
las venas de las piernas?____________________________
Have you had any broken bones (¿Ha tenido algun
hueso roto?)______________________________________
Have you been treated for depression(¿Ha recibido
tratamiento para depresión?)________________________
Have you had seizures (¿Ha tenido convulsiones?)____
Have you had any problems with drugs or alcohol
(¿Tiene problema con alcohol o drogas?)______________
Do you have asthma (¿Tiene asma?)_________________
Have you had any paralysis(¿Ha tenido parálisis?)____
Do you have diabetes ? (¿Tienes Diabetes?)___________
Yes
(Sí)
No
(No)