Patient Questionnaire - Private Insurance

1
Name / Nombre
First Name
Last Name
2
Date of Birth / Fecha De Nacimiento* This field is required.
Date
Month
Day
Year
3
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
4
Please describe your problem to us and tell us when it started:* This field is required.Por favor describa su problema y díganos cuando empezó
5
Please indicate the name of all medications that you take on a regular or intermittent basis.Por favor indique el nombre de todos los medicamentos que usted toma regularmente o de manera intermitente.
6
NEUROLOG / NEUROLOGI
YES
NO
Chronic or persistent headache/Crónicos o persistentes dolores de cabeza
Row 0, Column 0
Row 0, Column 1
Loss of Consciousness/Pérdida del conocimiento
Row 1, Column 0
Row 1, Column 1
Epilepsy / Seizure (Epilepsia / Convulsión)
Row 2, Column 0
Row 2, Column 1
Herniated Disc/Hernia Discal
Row 3, Column 0
Row 3, Column 1
Trouble walking or standing/Problemas al caminar o al pararse
Row 4, Column 0
Row 4, Column 1
Difficulty with comprehension or speaking / Problemas de comprensión o al hablar
Row 5, Column 0
Row 5, Column 1
Paralysis or Weakness of arm / leg (Parálisis o debilidad de los brazos o piernas)
Row 6, Column 0
Row 6, Column 1
Persistent Numbness or tingling / Persistente entumecimiento u hormigueo
Row 7, Column 0
Row 7, Column 1
NECK PAIN / Dolor de cuello
Row 8, Column 0
Row 8, Column 1
LOW BACK PAIN / Dolor de espalda bajo
Row 9, Column 0
Row 9, Column 1
Anxiety / Ansiedad
Row 10, Column 0
Row 10, Column 1
Severe depression / Depresión severa
Row 11, Column 0
Row 11, Column 1
Severe mood swings / Oscilaciones severos del humor
Row 12, Column 0
Row 12, Column 1
Psychiatric illness / Enfermedad Psiquiátrica
Row 13, Column 0
Row 13, Column 1
Brain hemorrhage / Hemorragia en el cerebro
Row 14, Column 0
Row 14, Column 1
Tremor / Shaking Temblores
Row 15, Column 0
Row 15, Column 1
Loss of coordination / Perdidad de coordinación
Row 16, Column 0
Row 16, Column 1
Dizziness, Vertigo / Vértigos (Sensación de dar vueltas)
Row 17, Column 0
Row 17, Column 1
Unsteadiness, imbalance, falls / Desequilibrio, o caídas
Row 18, Column 0
Row 18, Column 1
Lightheadedness (Feeling faint) / Desvanecimientos (Como que se desmaya)
Row 19, Column 0
Row 19, Column 1
Memory problems / Problems de la memoria
Row 20, Column 0
Row 20, Column 1
Confusion / Confusión
Row 21, Column 0
Row 21, Column 1
Sleep disturbance / Perturbación al dormir
Row 22, Column 0
Row 22, Column 1
Head injury / Herida en la cabeza
Row 23, Column 0
Row 23, Column 1
Bowel or Bladder dysfunction / Problemas en los intestinos o la vejiga
Row 24, Column 0
Row 24, Column 1
Brain tumor / Tumor Cerebral
Row 25, Column 0
Row 25, Column 1
Facial Pain / Dolor Facial
Row 26, Column 0
Row 26, Column 1
Difficulty with SWALLOWING food or beverages / Dificultad al tragar alimentos o bebidas
Row 27, Column 0
Row 27, Column 1
Any eye injury / Alguna lesión en los ojos
Row 28, Column 0
Row 28, Column 1
Nystagmus (Jerky eye movements) / Movimiento de los ojos a tirones Nystagmoso
Row 29, Column 0
Row 29, Column 1
Hemorrhage in the eye / Hemorragia en los ojos
Row 30, Column 0
Row 30, Column 1
Drooping of one eyelid or side of the face / Decaimiento de un parpado o un lado de la cara
Row 31, Column 0
Row 31, Column 1
Chronic or persistent headache/Crónicos o persistentes dolores de cabeza
Loss of Consciousness/Pérdida del conocimiento
Epilepsy / Seizure (Epilepsia / Convulsión)
Herniated Disc/Hernia Discal
Trouble walking or standing/Problemas al caminar o al pararse
Difficulty with comprehension or speaking / Problemas de comprensión o al hablar
Paralysis or Weakness of arm / leg (Parálisis o debilidad de los brazos o piernas)
Persistent Numbness or tingling / Persistente entumecimiento u hormigueo
NECK PAIN / Dolor de cuello
LOW BACK PAIN / Dolor de espalda bajo
Anxiety / Ansiedad
Severe depression / Depresión severa
Severe mood swings / Oscilaciones severos del humor
Psychiatric illness / Enfermedad Psiquiátrica
Brain hemorrhage / Hemorragia en el cerebro
Tremor / Shaking Temblores
Loss of coordination / Perdidad de coordinación
Dizziness, Vertigo / Vértigos (Sensación de dar vueltas)
Unsteadiness, imbalance, falls / Desequilibrio, o caídas
Lightheadedness (Feeling faint) / Desvanecimientos (Como que se desmaya)
Memory problems / Problems de la memoria
Confusion / Confusión
Sleep disturbance / Perturbación al dormir
Head injury / Herida en la cabeza
Bowel or Bladder dysfunction / Problemas en los intestinos o la vejiga
Brain tumor / Tumor Cerebral
Facial Pain / Dolor Facial
Difficulty with SWALLOWING food or beverages / Dificultad al tragar alimentos o bebidas
Any eye injury / Alguna lesión en los ojos
Nystagmus (Jerky eye movements) / Movimiento de los ojos a tirones Nystagmoso
Hemorrhage in the eye / Hemorragia en los ojos
Drooping of one eyelid or side of the face / Decaimiento de un parpado o un lado de la cara
YES
Row 0, Column 0
NO
Row 0, Column 1
YES
Row 1, Column 0
NO
Row 1, Column 1
YES
Row 2, Column 0
NO
Row 2, Column 1
YES
Row 3, Column 0
NO
Row 3, Column 1
YES
Row 4, Column 0
NO
Row 4, Column 1
YES
Row 5, Column 0
NO
Row 5, Column 1
YES
Row 6, Column 0
NO
Row 6, Column 1
YES
Row 7, Column 0
NO
Row 7, Column 1
YES
Row 8, Column 0
NO
Row 8, Column 1
YES
Row 9, Column 0
NO
Row 9, Column 1
YES
Row 10, Column 0
NO
Row 10, Column 1
YES
Row 11, Column 0
NO
Row 11, Column 1
YES
Row 12, Column 0
NO
Row 12, Column 1
YES
Row 13, Column 0
NO
Row 13, Column 1
YES
Row 14, Column 0
NO
Row 14, Column 1
YES
Row 15, Column 0
NO
Row 15, Column 1
YES
Row 16, Column 0
NO
Row 16, Column 1
YES
Row 17, Column 0
NO
Row 17, Column 1
YES
Row 18, Column 0
NO
Row 18, Column 1
YES
Row 19, Column 0
NO
Row 19, Column 1
YES
Row 20, Column 0
NO
Row 20, Column 1
YES
Row 21, Column 0
NO
Row 21, Column 1
YES
Row 22, Column 0
NO
Row 22, Column 1
YES
Row 23, Column 0
NO
Row 23, Column 1
YES
Row 24, Column 0
NO
Row 24, Column 1
YES
Row 25, Column 0
NO
Row 25, Column 1
YES
Row 26, Column 0
NO
Row 26, Column 1
YES
Row 27, Column 0
NO
Row 27, Column 1
YES
Row 28, Column 0
NO
Row 28, Column 1
YES
Row 29, Column 0
NO
Row 29, Column 1
YES
Row 30, Column 0
NO
Row 30, Column 1
YES
Row 31, Column 0
NO
Row 31, Column 1
1 of 32
7
RESPIRATORY / RESPIRATORI
YES
NO
Wheezing / Sonidos en el pecho
Row 0, Column 0
Row 0, Column 1
Shortness of breath / Respiración acortada
Row 1, Column 0
Row 1, Column 1
Chronic / cough Tos crónica
Row 2, Column 0
Row 2, Column 1
Coughing up blood / Tos con sangre
Row 3, Column 0
Row 3, Column 1
Pneumonia / Pulmonía
Row 4, Column 0
Row 4, Column 1
Emphysema / Efisema
Row 5, Column 0
Row 5, Column 1
Asthma / Asma
Row 6, Column 0
Row 6, Column 1
Sinus infection requiring antibiotics / Infección de sinosistis que requiere antibióticos
Row 7, Column 0
Row 7, Column 1
Respiratory allergies / Alergia respiratoria
Row 8, Column 0
Row 8, Column 1
Frequent or persistent fever / Fiebres frecuentes o persistentes
Row 9, Column 0
Row 9, Column 1
Tuberculosis / Tuberculosis
Row 10, Column 0
Row 10, Column 1
Venereal (sexually transmitted) disease / Enfermedades venereas (Transmitidas Sexualmente)
Row 11, Column 0
Row 11, Column 1
AIDS / ARC / HIV Sida / HIV
Row 12, Column 0
Row 12, Column 1
Unusual susceptibility to infection / Inusual Sensibilidad a las infecciones
Row 13, Column 0
Row 13, Column 1
Do you drink Alcohol / Toma usted alcohol
Row 14, Column 0
Row 14, Column 1
Unexplained loss of energy or strength / Inexplicable pérdida de energía o fuerza
Row 15, Column 0
Row 15, Column 1
Unexplained loss of weight or appetite / Inexplicable pérdida de peso o apetito
Row 16, Column 0
Row 16, Column 1
Chronic fever or swollen glands / Fiebre crónica o glándulas inflamadas
Row 17, Column 0
Row 17, Column 1
Have you ever used recreational drugs / A utilizado alguna vez drogas
Row 18, Column 0
Row 18, Column 1
Do you smoke / Fuma usted
Row 19, Column 0
Row 19, Column 1
For how many years [1-5]-[5-10]-[10-15]-[20+] / Por cuántos años [1-5]-[5-10]-[10-15]-[20+]
Row 20, Column 0
Row 20, Column 1
How many packs per day / Cuantos paquetes por día
Row 21, Column 0
Row 21, Column 1
Wheezing / Sonidos en el pecho
Shortness of breath / Respiración acortada
Chronic / cough Tos crónica
Coughing up blood / Tos con sangre
Pneumonia / Pulmonía
Emphysema / Efisema
Asthma / Asma
Sinus infection requiring antibiotics / Infección de sinosistis que requiere antibióticos
Respiratory allergies / Alergia respiratoria
Frequent or persistent fever / Fiebres frecuentes o persistentes
Tuberculosis / Tuberculosis
Venereal (sexually transmitted) disease / Enfermedades venereas (Transmitidas Sexualmente)
AIDS / ARC / HIV Sida / HIV
Unusual susceptibility to infection / Inusual Sensibilidad a las infecciones
Do you drink Alcohol / Toma usted alcohol
Unexplained loss of energy or strength / Inexplicable pérdida de energía o fuerza
Unexplained loss of weight or appetite / Inexplicable pérdida de peso o apetito
Chronic fever or swollen glands / Fiebre crónica o glándulas inflamadas
Have you ever used recreational drugs / A utilizado alguna vez drogas
Do you smoke / Fuma usted
For how many years [1-5]-[5-10]-[10-15]-[20+] / Por cuántos años [1-5]-[5-10]-[10-15]-[20+]
How many packs per day / Cuantos paquetes por día
YES
Row 0, Column 0
NO
Row 0, Column 1
YES
Row 1, Column 0
NO
Row 1, Column 1
YES
Row 2, Column 0
NO
Row 2, Column 1
YES
Row 3, Column 0
NO
Row 3, Column 1
YES
Row 4, Column 0
NO
Row 4, Column 1
YES
Row 5, Column 0
NO
Row 5, Column 1
YES
Row 6, Column 0
NO
Row 6, Column 1
YES
Row 7, Column 0
NO
Row 7, Column 1
YES
Row 8, Column 0
NO
Row 8, Column 1
YES
Row 9, Column 0
NO
Row 9, Column 1
YES
Row 10, Column 0
NO
Row 10, Column 1
YES
Row 11, Column 0
NO
Row 11, Column 1
YES
Row 12, Column 0
NO
Row 12, Column 1
YES
Row 13, Column 0
NO
Row 13, Column 1
YES
Row 14, Column 0
NO
Row 14, Column 1
YES
Row 15, Column 0
NO
Row 15, Column 1
YES
Row 16, Column 0
NO
Row 16, Column 1
YES
Row 17, Column 0
NO
Row 17, Column 1
YES
Row 18, Column 0
NO
Row 18, Column 1
YES
Row 19, Column 0
NO
Row 19, Column 1
YES
Row 20, Column 0
NO
Row 20, Column 1
YES
Row 21, Column 0
NO
Row 21, Column 1
1 of 22
8
EAR, NOSE AND THROAT / OÍDOS, NARIZ, Y GARGANTA
YES
NO
Frequent or severe ear infections / Severas o frecuentes infecciones en los oídos
Row 0, Column 0
Row 0, Column 1
Hearing loss / Perdida de la audición
Row 1, Column 0
Row 1, Column 1
Ringing in the ears / Zumbido en los oídos
Row 2, Column 0
Row 2, Column 1
Nasal / Respiratory allergies / Alergias nasales o respiratorias
Row 3, Column 0
Row 3, Column 1
Vertigo / Spinning sensation Vértigo (Sensación de dar vueltas)
Row 4, Column 0
Row 4, Column 1
Fullness in the ears / Sensación de tener los oidos llenos o algo en ellos
Row 5, Column 0
Row 5, Column 1
Frequent or severe ear infections / Severas o frecuentes infecciones en los oídos
Hearing loss / Perdida de la audición
Ringing in the ears / Zumbido en los oídos
Nasal / Respiratory allergies / Alergias nasales o respiratorias
Vertigo / Spinning sensation Vértigo (Sensación de dar vueltas)
Fullness in the ears / Sensación de tener los oidos llenos o algo en ellos
YES
Row 0, Column 0
NO
Row 0, Column 1
YES
Row 1, Column 0
NO
Row 1, Column 1
YES
Row 2, Column 0
NO
Row 2, Column 1
YES
Row 3, Column 0
NO
Row 3, Column 1
YES
Row 4, Column 0
NO
Row 4, Column 1
YES
Row 5, Column 0
NO
Row 5, Column 1
1 of 6
9
SKIN / PIEL
YES
NO
Multiple birth marks
Row 0, Column 0
Row 0, Column 1
Skin Tumor / Tumor en la piel
Row 1, Column 0
Row 1, Column 1
Multiple birth marks
Skin Tumor / Tumor en la piel
YES
Row 0, Column 0
NO
Row 0, Column 1
YES
Row 1, Column 0
NO
Row 1, Column 1
1 of 2
10
HEART AND CIRCULATORY / CARAZÓN Y CIRCULATORIO
YES
NO
Heart attack / Ataque al corazón
Row 0, Column 0
Row 0, Column 1
Heart failure / Paro cardíaco
Row 1, Column 0
Row 1, Column 1
Irregular heart rhythm / Ritmos irregulares del corazón
Row 2, Column 0
Row 2, Column 1
Palpitations / Palpitaciones
Row 3, Column 0
Row 3, Column 1
Heart murmur / Soplo al corazón
Row 4, Column 0
Row 4, Column 1
Chest pain / Dolor del pecho
Row 5, Column 0
Row 5, Column 1
Heart surgery / Cirugía del corazón
Row 6, Column 0
Row 6, Column 1
Pace maker / Pacificador en el corazón
Row 7, Column 0
Row 7, Column 1
Low Blood Pressure / Baja presión arterial
Row 8, Column 0
Row 8, Column 1
Heart attack / Ataque al corazón
Heart failure / Paro cardíaco
Irregular heart rhythm / Ritmos irregulares del corazón
Palpitations / Palpitaciones
Heart murmur / Soplo al corazón
Chest pain / Dolor del pecho
Heart surgery / Cirugía del corazón
Pace maker / Pacificador en el corazón
Low Blood Pressure / Baja presión arterial
YES
Row 0, Column 0
NO
Row 0, Column 1
YES
Row 1, Column 0
NO
Row 1, Column 1
YES
Row 2, Column 0
NO
Row 2, Column 1
YES
Row 3, Column 0
NO
Row 3, Column 1
YES
Row 4, Column 0
NO
Row 4, Column 1
YES
Row 5, Column 0
NO
Row 5, Column 1
YES
Row 6, Column 0
NO
Row 6, Column 1
YES
Row 7, Column 0
NO
Row 7, Column 1
YES
Row 8, Column 0
NO
Row 8, Column 1
1 of 9
11
BLOOD / LYMPHATICS / SANGRE / LYMPHATICOS
YES
NO
Leukemia / Leucemia
Row 0, Column 0
Row 0, Column 1
Bleeding tendency / Tendencia a sangrar demasiado
Row 1, Column 0
Row 1, Column 1
Clotting tendency (Thrombosis) / Tendencia de coagulación (Trombosis)
Row 2, Column 0
Row 2, Column 1
Blood Transfusions / Transfusiones de sangre
Row 3, Column 0
Row 3, Column 1
Other Blood Disorders / Otros problemas de sangres
Row 4, Column 0
Row 4, Column 1
Swollen Lymph nodes / glands Ganglios o glándulas inflamadas
Row 5, Column 0
Row 5, Column 1
Anemia / Anemia
Row 6, Column 0
Row 6, Column 1
Leukemia / Leucemia
Bleeding tendency / Tendencia a sangrar demasiado
Clotting tendency (Thrombosis) / Tendencia de coagulación (Trombosis)
Blood Transfusions / Transfusiones de sangre
Other Blood Disorders / Otros problemas de sangres
Swollen Lymph nodes / glands Ganglios o glándulas inflamadas
Anemia / Anemia
YES
Row 0, Column 0
NO
Row 0, Column 1
YES
Row 1, Column 0
NO
Row 1, Column 1
YES
Row 2, Column 0
NO
Row 2, Column 1
YES
Row 3, Column 0
NO
Row 3, Column 1
YES
Row 4, Column 0
NO
Row 4, Column 1
YES
Row 5, Column 0
NO
Row 5, Column 1
YES
Row 6, Column 0
NO
Row 6, Column 1
1 of 7
12
CANCER / CÁNCER
YES
NO
Cancer of any type / Cáncer de cualquier tipo
Row 0, Column 0
Row 0, Column 1
Chemotherapy / Quimioterapia
Row 1, Column 0
Row 1, Column 1
Radiation therapy / Terapia de radiación
Row 2, Column 0
Row 2, Column 1
Cancer of any type / Cáncer de cualquier tipo
Chemotherapy / Quimioterapia
Radiation therapy / Terapia de radiación
YES
Row 0, Column 0
NO
Row 0, Column 1
YES
Row 1, Column 0
NO
Row 1, Column 1
YES
Row 2, Column 0
NO
Row 2, Column 1
1 of 3
13
GASTROINTESTINAL / GASTROINTESTINAL
YES
NO
Chronic diarrhea / Diarrea crónica
Row 0, Column 0
Row 0, Column 1
Bloody stool / Sangre al evacuar
Row 1, Column 0
Row 1, Column 1
Frequent abdominal pain or cramps / Frecuentes dolores abdominales o calambres
Row 2, Column 0
Row 2, Column 1
Difficulty swallowing / Dificultad al tragar
Row 3, Column 0
Row 3, Column 1
Peptic Ulcer / Ulceras
Row 4, Column 0
Row 4, Column 1
Chronic diarrhea / Diarrea crónica
Bloody stool / Sangre al evacuar
Frequent abdominal pain or cramps / Frecuentes dolores abdominales o calambres
Difficulty swallowing / Dificultad al tragar
Peptic Ulcer / Ulceras
YES
Row 0, Column 0
NO
Row 0, Column 1
YES
Row 1, Column 0
NO
Row 1, Column 1
YES
Row 2, Column 0
NO
Row 2, Column 1
YES
Row 3, Column 0
NO
Row 3, Column 1
YES
Row 4, Column 0
NO
Row 4, Column 1
1 of 5
14
ENDOCRINE / HORMONAL / HORMONAL / ENDOCRINALES
YES
NO
Disease of endocrine glands / Enfermedad de las glándulas endocrinarias
Row 0, Column 0
Row 0, Column 1
Hypothalamus, Pituitary, Thyroid, Adrenals, Parathyroid / Hipotálamo, Pituitario, Tiroides, Paratiroides
Row 1, Column 0
Row 1, Column 1
Diabetes / Diabetes
Row 2, Column 0
Row 2, Column 1
Disease of endocrine glands / Enfermedad de las glándulas endocrinarias
Hypothalamus, Pituitary, Thyroid, Adrenals, Parathyroid / Hipotálamo, Pituitario, Tiroides, Paratiroides
Diabetes / Diabetes
YES
Row 0, Column 0
NO
Row 0, Column 1
YES
Row 1, Column 0
NO
Row 1, Column 1
YES
Row 2, Column 0
NO
Row 2, Column 1
1 of 3
15
OB-GYNECOLOGY / OB-GYNECOLOGIA S
YES
NO
Are you pregnant / Está usted embarazada
Row 0, Column 0
Row 0, Column 1
Have you had any complications related to child birth / Ha tenido usted complicaciones al dar a luz
Row 1, Column 0
Row 1, Column 1
Excessive bleeding during menses / Sangramiento exceso durante la menstruación
Row 2, Column 0
Row 2, Column 1
Are you pregnant / Está usted embarazada
Have you had any complications related to child birth / Ha tenido usted complicaciones al dar a luz
Excessive bleeding during menses / Sangramiento exceso durante la menstruación
YES
Row 0, Column 0
NO
Row 0, Column 1
YES
Row 1, Column 0
NO
Row 1, Column 1
YES
Row 2, Column 0
NO
Row 2, Column 1
1 of 3
16
EXPOSURE / EXPOSURE
YES
NO
Have you ever been exposed to poison gases or chemicals / Ha sido usted expuesto a gases venenosos o quimicos
Row 0, Column 0
Row 0, Column 1
Have you ever been exposed to poison gases or chemicals / Ha sido usted expuesto a gases venenosos o quimicos
YES
Row 0, Column 0
NO
Row 0, Column 1
Should be Empty: