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ill allergic
tuberculosis light-headed
a disease a medication
1. Are you allergic* to any medications? * ( ), alrgico, , no yes If so, what medication? _______________ 3. Do you take medicine for high blood pressure? no yes 5. Are you experiencing (=feeling) pain anywhere in your body today? no yes If so, where? _______________ 7. Have you ever become ill while you were visiting another country? no yes If so, did you have to see a doctor? no yes 9. Do you have any shortness of breath* today? no yes
*difficulty breathing,
, falta de aire, , 11. When was your last medical checkup*? * , revisin mdica, chequeo, ,
____ last medical checkup was ___ __________ ago.
His/Her OR # months/years
no yes *
, ,
ill allergic
tuberculosis light-headed
a disease a medication
4. Have you felt light-headed* anytime this week? , estar mareado, , no yes If so, why do you think you felt light-headed? _________________________ 6. What food have you eaten so far* today? * , hasta aqu/ahora, , ___________________________________ 8. Do you smoke? no yes If so, how many cigarettes do you smoke a day? __ 10. Do you have a history of heart disease (, enfermedad, , )in your family? no yes If so, which relative has had heart disease? _______________ 12. Are you expecting? (=pregnant) no yes
2002fallflexhealth07Repaired Roland Trego 08/30/2002 rev. 10/19/2013 10:20 AM
( ), alrgico, ,