PERSONAL INFORMATION

1. WHAT’S YOUR NAME? My name is …

2. WHAT’S YOUR SURNAME/LAST NAME? My last name is …
3. WHAT’S YOUR ID NUMBER? 4-3-5-6-7-8-9-0
4. WHAT’S YOUR MARITAL STATUS? Single /married/separated/divorced/widow(ed)
5. HOW OLD ARE YOU? WHAT’S YOUR AGE? 78 years old/78 years/78
6. WHAT’S YOUR DATE OF BIRTH? 1th /July/1980
7. WHAT’S YOUR ADDRESS? 123 Pierola Street/Avenue District : Paucarpata
8. WHAT’S YOUR TELEPHONE NUMBER? 5-5-6-7-8-6
9. WHAT’S YOUR CELLPHONE NUMBER? 9-8-7-5-6-7-8-8
10. WHAT’S YOUR PASSPORT NUMBER? 5-6-7-Y-8-9-M-N
11. WHAT’S YOUR EMAIL ADDRESS? jon_7/@gmail.com
12. WHERE ARE YOU FROM? I’m from Arequipa
13. WHAT’S YOUR NATIONALITY? Peruvian
14. WHAT’S YOUR OCCUPATION/JOB? I’m a …
15. HOW MANY CHILDREN DO YOU HAVE? No children/one child/two children
16. DO YOU HAVE A HEALTH INSURANCE? Yes /No
17. DO YOU HAVE PETS? Yes /No
18. DO YOU HAVE ANY RELATIVES LIVING HERE? Yes /No
19. COULD YOU GIVE ME SOME EMERGENCY CONTACTS? (name and phone)
20. WHAT’S YOUR EDUCATION STATUS? Primary /high school/ higher education

HEALTH INFORMATION
1. ARE YOU PREGNANT? Yes /No
2. WHAT’S YOUR WEIGH? 68 k
3. WHAT’S YOUR HEIGH? 1m45cm
4. WHAT’S YOUR BLOOD TYPE? (A+, A-, B+, B-, O+, O-, AB+, AB-).
5. ARE YOU ALLERGIC TO PENICILLIN? Yes /No
6. ARE YOU ALLERGIC? Yes /No
7. WHAT KIND OF ALLERGIES DO YOU HAVE? I’m allergic to dust/pollen/chocolate/seafood
8. ARE YOU ASTHMATIC, DIABETIC, EPILEPTIC OR HYPERTENSE? None of them / I’m …
9. DO YOU SUFFER FROM HIGH OR LOW PRESSURE? Low pressure/High presure /None of them
10. DO YOU SMOKE? Yes /No
11. DO YOU DRINK ALCOHOL? Yes /No
12. DO YOU USE DRUGS? Yes /No
13. HOW OFTEN DO YOU DO EXERCISE? Never/Once a week/Twice a week/Three times a week
14. HOW OFTEN DO YOU EAT VEGETABLES? never/once a week/twice a week/three times a week
15. HOW OFTEN DO YOU EAT FRUIT? never/once a week/twice a week/three times a week
16. HOW OFTEN DO YOU DRINK WATER? never/once a week/twice a week/three times a week
17. DO YOU TAKE ANY MEDICATION? Yes /No
18. WHAT KIND OF MEDICATION DO YOU TAKE? I take…
19. DO YOU HAVE ANY SURGERIES OR PROCEDURES? Yes /No
Teacher Andrea A L/all rigths reserved/English for medical and Healthcare professionals
19. DO YOU HAVE ANY PROCEDURE OR SURGERY?

SYMPTOMS INFORMATION
1. WHAT SYMPTOMS DO YOU HAVE? WHAT ARE YOUR SYMPTOMS?

Headache / toothache/ stomachache/backache/ earache/ muscular aches / indigestión/ vomits/

nausea/ dizziness/sore throat/nasal congestion/runny nose/cough/tiredness/diarrea/Fatigue / chills
and shivering/fever/weakness/loss of apetite/dry mouth/ flatulence/ heartburn/ constipation/
itching/ anxiety/depression
Others: ______

2. SINCE WHEN DO YOU HAVE THESE SYMPTOMS?

Since yesterday / two days ago / since last week/ one month ago/since 8 am…

3. WHERE DOES IT HURT?

Head /neck /back and shoulder/arm and hand/pelvic and abdominal pain/ hip/ leg and foot /knee /
whole body
Others:_____
4. WHEN DID YOUR SYMPTOMS START?
5. HAVE YOUR SYMPTOMS GOTTEN BETTER OR WORSE?
6. DO YOU HAVE A FAMILY HISTORY OF THIS?
7. WHAT PRESCRIPTION MEDICATIONS, OVER-THE-COUNTER MEDICATIONS, VITAMINS, AND
SUPPLEMENTS DO YOU TAKE?
8. HAVE YOU SERVED IN THE MILITARY?
9. ARE YOU SEXUALLY ACTIVE?
10. DO YOU USE ANY KIND OF TOBACCO, ILLICIT DRUGS OR ALCOHOL?
11. WHAT IS THE PROBLEM?
12. HOW ARE YOU FEELING?
13. WHEN DID YOUR PROBLEM/SYMPTOMS BEGIN?
14. WHAT WERE YOU DOING WHEN THE SYMPTOMS BEGAN?
15. WHAT MAKES THE PROBLEM OR SYMPTOMS WORSE?
16. WHAT MAKES THE PROBLEM OR SYMPTOMS BETTER?
17. HOW LONG HAVE YOU HAD THESE SYMPTOMS?
18. HOW PAINFUL IS IT?
19. HOW OFTEN DO YOU EXPERIENCE THESE SYMPTOMS?
20. WHAT OTHER SYMPTOMS DO YOU HAVE?
21. HAVE THESE SYMPTOMS OCCURRED BEFORE? IF SO HOW OFTEN AND WHEN DO THEY OCCUR?
22. HAVE YOU HAD SIMILAR PROBLEMS IN THE PAST?
23. HAS ANYONE ELSE LOOKED AT OR CARED FOR THESE SYMPTOMS?
24. HOW DO THESE PROBLEMS AFFECT YOUR DAILY ACTIVITIES?
25. DID ANYTHING YOU KNOW OF CAUSE THESE SYMPTOMS?

Teacher Andrea A L/all rigths reserved/English for medical and Healthcare professionals