CHRONIC DISEASE REGISTRATION AND CONTROL CARD.

IDENTIFICATION DATA BACKGROUND

RELATIVES: GRANDPARENTS
PROCEEDINGS: PARENTS
BIRTHDATE: AGE: ENF. CARDIOVASCULAR
NAMES): LAST NAME: HTA
MOTHER'S LAST NAME: CURP: DIABETES
WEIGHT: SIZE: BMI: DYSLIPIDEMIAS
SEX: MAN ( ) WOMEN ( ) OBESITY
HOME: ENF. CEREBROVASCULAR
PHONE: PERMANENT: CELL PHONE: PERSONAL:
EMAIL: ENF. CEREBROVAS ( ) ENF. CARDIOVAS
DIAGNOSIS(S): OVERWEIGHT ( ) TOBACCO
ADJUSTMENT TO TREATMENT: SEDENTARISM ( ) TUBERCULOSIS
ASCRIPTION CLINIC: MENOPAUSE ( ) REMPLA THERAPY
BASIC DIAGNOSTIC DATA
1. DIABETES MELLITUS 2. ART HYPERTENSION
CONTROL ENTRY: TYPE 1 ( )2( ) DX YEAR: CONTROL ENTRY:
DETECTION MADE BY: INQUIRY SYMPTOMS DETECTION MADE BY: INQUIRY
PREVIOUS TREATMENT: PHARMACOLOGICAL NON-
) PREVIOUS TREATMENT: PHARMACOLOGICAL ( )
( ) PHARMACOLOGICAL (
FASTING GLUCEMIA (mg/dl)
BASELINE DATA: BASELINE DATA: BLOOD PRESSURE
SYMPTOMATOLOGY:
HbA1c%
3. OBESITY 4. DYSLIPIDEMIA
CONTROL ENTRY: YEAR OF DX CONTROL ENTRY:
DETECTION MADE BY: INQUIRY SYMPTOMS DETECTION MADE BY: INQUIRY
PREVIOUS TREATMENT: PHARMACOLOGICAL ( ) NON-PHARMACOLOGICAL ( ) PREVIOUS TREATMENT: PHARMACOLOGICAL ( )
BASELINE DATA: WEIGHT: BMI: BASELINE DATA: TOTAL CHOLESTEROL ____
__
WAIST CIRCUMFERENCE: TRIGLYCERIDES: _______
5. METABOLIC SYNDROME PHARMACOLOGICAL AND NON-FA TREATMENT
DATE OF ADMISSION DUE TO METABOLIC SYNDROME: 1 7
YEAR OF DIAGNOSIS: 2 8
DIAGNOSES THAT INCLUDE THE SYNDROME 3 9
4 10
5 11
 6 12

CONTROL DATA
BLOOD PRESSURE GLUCEMIA CHOLESTEROL
TRIGLYCERIDE
DATE WEIGHT BMI SYSTOLIC DIASTOLIC ON FASTING CASUAL TOTAL LDL HDL S

*Write in the box(es) the number that corresponds to the condition according to the consultation made (1. Diabetes, 2. Dyslipidemias, 5.
Metabolic Syndrome), specifying with a YES, yes it is controlled, and with a NO, yes it is not controlled; eg YES.

***If the patient was referred to your outpatient unit, write down the number preceding the level: 1. Consul unit the reason: DCM. Metabolic
imbalance, ECR. Crisis state.
IN CASE OF WITHDRAWAL: Write down the number that corresponds to the cause that motivated it:
sick leave: I refuse treatment Temporary leave: Other (specify):
 NONE BROTHERS AND UNCLES

( ) HIV ( )
( ) ALCOHOL ( )
( ) MENOPAU ( )
HORMONAL ZO ( )

WATERLAND
YEAR OF DX
SYMPTOMS
NON-PHARMACOLOGICAL ( )
SYSTOLIC:
DIASTOLIC:
Yes
YEAR OF DX
SYMPTOMS
NON-PHARMACOLOGICAL ( )
LDL _______ HDL ________

CURRENT RMACOLOGY:
 COMPLICATIO
CHECKED * NS** REFERENCE***

Hypertension, 3. Obesity, 4.
emplo: Diabetic contr o side 1

external ta, 2. general hospital and