MEDICAL RECORD Date:

08/24/22
PERSONAL HISTORY.
NAME:

LAST NAME:
ID :
BIRTHDATE:
AGE:
PLACE:
CEL:
JOB OCCUPATION:
NUMBER OF HOURS:
CHILDREN: TYPE OF DELIVERY.
SMOKE. DRINK ALCOHOL.
CLINICAL HISTORY:

BLOOD TYPE:
RESPIRATORY PROBLEMS:
Which is it?
WHAT MEDICATIONS DO YOU TAKE?
CARDIAC PROBLEMS? What medications do you take?
TACHYCARDIA: HYPERTENSION:
HYPOTENTION: ACV:
DIABETES: CHOLESTERO
L:
OVERWEIGHT:
RHEUMATIC DISEASES:

DIGESTIVE DISEASES:
TUMORS:
CHRONIC DISEASES:
KIDNEY PROBLEMS:
BLADDER PROBLEMS:
SURGICAL HISTORY:
CESAREAN COVID:
SECTIONS:
ALLERGIE WHICH
S: IS IT:
VARICOS PRONOUNCED OR MILD:
E VEINS:
THROMBOSI CURRENT
S:
IMPLANTS PREGNANCY:
OR PROSTHESIS:
SPECIFY:
IUD: TATTOOS: TIME:
STDs SPORT: HOURS:
:
REASON FOR CONSULTATION:
TYPE OF PAIN:
WHAT ZONE: PAIN LEVEL:
WITH THIS FORM YOU ARE ESTABLISHING THAT ALL YOUR
STATEMENTS ARE REAL.
THAT YOU ARE NOT HIDING INFORMATION ABOUT THE
STATE OF YOUR HEALTH.
AND THAT YOU ARE RESPONSIBLE FOR IT.

SIGNATURE AND SIGNATURE

ACLARATION
FROM THE OF THE
MASS THERAPIST.
PATIENT.