Medical History/ Historial médico

Medical History/ Historial médico
This form is for your use only and is to be kept with your personal records should the need arise.
_____________________________
Student Name
_____________________________
Date of Birth
Nombre del alumno
Fecha de nacimiento
Please indicate if you have a history of any of the following:
Indique si padece alguna de las siguientes enfermedades:
Diabetes
yes no
Asthma
Diabetes
Other endocrine disease yes
yes no
Asma
no
Blood disease
yes no
Enfermedad sanguínea
Neurological disorder yes no
Kidney disease
Otro enfermedad endocrina
Desorden neurológico
Enfermedad de riñón
yes no
Heart disease yes no
Psychiatric disorder yes no
Liver disease yes no
Enfermedad cardíaca
Problema Psiquiátrico
Enfermedad hepática
If you mark yes, please provide an explanation/En caso afirmativo, explique por favor
_______________________________________________________________
______
__________________________________________________________
___________
_____________________________________________________________________
Are you allergic to any medications? Yes No
¿Tiene alergia a algún medicamento?
If yes, please list/En caso afirmativo, por favor indique a cuáles:
List any medications you take on a regular basis.
Anote los medicamentos que toma de forma habitual
Do you have any other kinds of allergic conditions such as hay fever, asthma, etc? Yes
If yes, please list.
¿Tiene algún otro tipo de alergia? En caso afirmativo por favor indique cual
No
Please list any significant current health problems.
Indique si tiene algún problema de salud en la actualidad
List any significant past health problems.
Indique si ha padecido algún problema de salud en el pasado
Have you ever been hospitalized. Yes
No
If yes, indicate why and when.
¿Ha sido hospitalizado alguna vez? En caso afirmativo indique el motivo y la fecha
Have you ever had an operation? Yes
No
If yes, please specify.
¿Ha sufrido alguna operación quirúrgica? En caso afirmativo especifique
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Do you have any dietary restrictions for medical reasons? Yes
No
If yes, please specify.
¿Tiene alguna restricción alimentaria por razones médicas? En caso afirmativo especifique:
In case of a health emergency go immediately to the Emergency room at any of these hospitals:
En caso de una urgencia médica acuda a Urgencias en los siguientes hospitales:
HOSPITAL SANITAS LA ZARZUELA
Calle de Pleyades, 25,
28023 Madrid
HOSPITAL SANITAS LA MORALEJA
Av. de Francisco Pi y Margall, 81
28050 Madrid
HOSPITAL DE MADRID
Plaza Conde del Valle Suchil, 16.
(Metro: San Bernardo, Lines 2 and 4)
T: 91 447 6600
SANATORIO EL ROSARIO
Príncipe de Vergara, 53
(Metro: Núñez de Balboa, Lines 5 and 9)
T: 91 435 91 00
And contact the Saint Louis University Madrid Health & Safety Emergency Number:
Y póngase en contacto con Saint Louis University, Madrid en el teléfono para urgencias médicas y de seguridad
Tel: (34) 638 763 758
Please note: MEDICAL PRECONDITIONS AND STUDENT ACCOMMODATIONS AT
SLU-MADRID
Students with any medical precondition (physical or mental) will be responsible for following the guidelines provided by their
physicians in their home countries and for seeking the adequate resources to continue any treatment while they study in
Madrid. Students may use their Sanitas Medical Insurance which is included in the tuition price. Students may contact Dr.
Borrás, general practitioner in Sanitas, who will be able to refer you to any specialist within Sanitas at [email protected]
or [email protected] and/or SLU-Madrid Counseling Center at [email protected].
While SLU-Madrid will make every effort to support students with severe medical conditions so that they may be capable of
successfully completing their academic work, at times, such medical conditions are so severe that they negatively affect both the
student as well as other members of the campus community. Please review the following list of available accommodations for students
with special needs: Student Accommodations at the SLU-Madrid Campus.
Students with such conditions may continue to study at SLU-Madrid and access services such as Housing as long as the medical
condition does not affect the coexistence of the student among the SLU-Madrid community members to the extent of being disturbing
and disruptive. Examples of these disturbing/disruptive behaviors include, but are not limited to: poor social interaction with host
family/roommates, or social interaction that is aggressive, hostile, threatening, or disturbing to others; behavior suggesting the
presence of a medical and/or mental illness that is causing significant disruption/distress to the student's family/roommates, such as
depression (e.g., self-injurious behavior, suicide threats/attempts, isolating oneself in the room while at home, etc.), anxiety disorders
(e.g., becoming hostile or excessively anxious when family members/roommates do not follow rigid routines, etc.), eating disorders
(e.g., excessive weight loss, binge eating, vomiting frequently, or unusual requests regarding food and menus, etc.), and substance
abuse, among others.
When the presence of such behaviors is detected, the Department of Student Life, in coordination with the University Counseling
Center, and the Dean's Office, will make a determination regarding the appropriate action required, including, but not limited to:
continuing academic studies, while receiving appropriate treatment for the medical condition; leaving the home stay; taking a leave of
absence; or withdrawing from SLU-Madrid.
Please look at our Counseling Services webpage in case you think you may need a counselor to deal with your medical condition,
time of recovery, etc.
The following is a list of medical health professionals who accept Sanitas insurance. For a comprehensive list, please visit the Sanitas
website (www.sanitas.es).
Updated Jan 14, 2016
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