Sociedad Amigos de los Niños
MEDICAL BRIGADE DEPARTMENT
PATIENT INFORMATION SHEET
Name
/Nombre
Date
/Feche
Age
/Edad
Sex
/Sexto
Community
/Comunidad
Alergic to medicines/Alergico(ca) a algona medicina: Yes/si
No
Current medication/Medicinas que esta tomando
No
Weight/Peso:
Temperature/Temperatura:
Pregnant/Emabarazada Yes/si
No
Blood Preasure/Presion Alterial
Blood Glucose/Azucar
Symptoms/Sintomas:
DIAGNOSTIC
Respiratory/Respiratorio
G.I.
Dermatology/Dermatologico
Cough / Tos
Gastritis
Eczema / Exema
Asthma / Asma
Reflox / Acidos
Piogena / Gramos
Cold / Gripe
Colitis / Colitis
Fungus / Hongos
Rinitis / Renitis
Diarrhea / Diarrea
Scabies / Escabiosis
Sinusitis / Sinositis
Vomiting / Vomito
Vascular Ulcers / Ulceras Varicosas
Pneumonia / Neumonia
Nausea
Bronchitis / Broqhitis
Parasites / Parasitos
Otitis
Tosilitis / Amigdalitis
Neuro/Psyche
ID/Enf. Infecciosas
Cardiovascular / Metabolic
Migraine / Migraña
Conjunctivitis / Conjunctivitis
Hypertension / Hipertension
Headache / Cafalea
Dengue
Diabetes / Diabetes
Depression / Depresion
Malaria
Stroke / Derrame
Anxiety / Ansieda
Vaginitis
Malnutrition / Desnuticion
Vertigo / Vertigo
STD / Enfermedades Venereas
Dysmenorrhea / Dismenorrea
Unirary Track Infection / ITU
Masculoskeletal/Mascular
Back Pain / Lumbalgias
Arthritis / Artritis
Other / Otros:
TREATMENT / TRATAMIENTO:
Vitamins/Vitaminas
Tylenol
Ibuprofen
Albendazole
Amoxicillin / Amoxicilina
Other/Otros
Chronic Problem / Problema Cronico
Referral / Remission
Group
Sociedad Amigos de los Niños / MEDICAL BRIGADE DEPARTMENT