NAME: ____________________________AGE: _____ PHONE: __________________HEIGHT: _____ WEIGHT:_____ CHIEF COMPLAINT: _____________________________________________________________________________ ______________________________________________________________________________________________ SUBJECTIVE SIGNS AND SYMPTONS: ________________________________________________________________ ______________________________________________________________________________________________ PREVIOUS TREATMENT: __________________________________________________________________________ ______________________________________________________________________________________________ OTHER PODIATRIC PROBLEMS: _________________________________________________________________________________
BUNIONS CORNS CALLUSES INGROWN NAILS HEEL PAIN ARCH PAIN ANKLE PAIN METATARSALGIA
HOME TREATMENT FOR THIS CONDITION: __________________________________________________________________________________ _____________________________________________________________________________________________________________________________ HAVE YOU PERSONALLY EVER BEEN TREATED FOR ANY OF THE FOLLOWING CONDITIONS?
CHEST PAIN ASTHMA KIDNEY PROB ANEMIA LIVER DISEASE BLEEDING PROB FOOT ULCERS
HEART PROB ARTHRITIS BLOOD CLOTS STROKE NEUROPATHY HIGH CHOLESTEROL GOUT
SICKLE CELL DIABETES THYROID PROB CANCER STOMACH ULCERS HIGH BLOOD PRESSURE
OTHER: _____________________________________________________________________________________________________________________
I AM NOT CURRENTLY BEING TREATED FOR ANY CONDITIONS. HAS ANYONE IN YOUR IMMEDIATE FAMILY EVER BEEN TREATED FOR ANY OF THE FOLLOWING CONDITIONS?
CHEST PAIN ASTHMA KIDNEY PROB ANEMIA LIVER DISEASE BLEEDING PROB FOOT ULCERS
HEART PROB ARTHRITIS BLOOD CLOTS STROKE NEUROPATHY HIGH CHOLESTEROL GOUT
SICKLE CELL DIABETES THYROID PROB CANCER STOMACH ULCERS HIGH BLOOD PRESSURE
OTHER: ____________________________________________________________________________________ ADOPTED
NO ONE IN MY IMMEDIATE FAMILY HAS EVER BEEN TREATED FOR ANY OF THE ABOVE CONDITIONS.
PREVIOUS SURGERIES: __________________________________________________________________________________________ ______________________________________________________________________________________________ ALCOHOL: _____ NONE SOCIAL MODERATE HEAVY TOBACCO: CIG/DAY ______ HOW LONG? ______ ARE YOU PREGNANT? ______ CURRENT MEDICATIONS: ______________________________________________________________________________________ ________________________________________________________________________________________________________________
ALLERGIES: I HAVE NO ALLERGIES. I AM ALLERGIC TO THE FOLLOWING:
TYLENOL TAPE ASA KEFLEX CODIENE LATEX IODINE
PENICILLIN SULFA MORTIN DARVON NOVOCAINE DEMEROL SHELL FISH
OTHER: _________________________________________________________________________
PGx Cardio Farmacogenética en Cardiología Las enfermedades cardiovasculares son la primera El análisis proporciona información relevante acerca de causa de muerte y hospitalización en la población los 52 fármacos más utilizados, a partir del estudio de 49 española, ocasionando el 40% de todas las defunciones. polimorfismos genéticos en 27 genes descritos en la bibliografía c
¿Es usted víctima de violencia intrafamiliar? No hay razón para que usted deba soportar maltratos. (d) Relación informal de cuidado - existe entre dos personas si una de ellas es o fue dependiente Si una persona con quien usted mantiene una relación de la otra (un cuidador) que ayuda a la persona en una actividad del diario vivir (actividades de cuidado personal). Este cuidado person