V Expociencias de Argentina 5, 6 y 7 de Octubre- Santa Rosa – La Pampa
MEDICAL RECORD: Name …………………………… Surnames ……………………………………. DO YOU HAVE A MEDICAL INSURENCE? Is so specify the following:
YES
NO
WHICH? MEMBERSHIP NUMBER: EMERGENCY PHONE NUMBER: IF NEEDED, CONTACT: NAME AND SURNAME:
TELEPHONE: (
)
Relationship: NAME AND SURNAME:
TELEPHONO: (
)
Relationship: BLOOD GROUP: WEIGHT: ¿HAVE YOU EVER HAD OR DO YOU HAVE ANY OF THESE ILLNESSES? If so indicate it with an “X” and specify if necessary. ASTHMA
(
)
DIABETES
(
)
RESPIRATORY DISEASES
(
)
EPILEPSY
(
)
CARDIOVASCULAR DISEASES
(
)
CONVULSIONS
(
)
DIGESTIVE DISEASES
(
)
HERNIAS
(
)
HEPATITIS
(
)
COELIAC DISEASE
(
)
ANEMIA
(
)
STRONG HEADACHES
(
)
HYPERTENSION
(
)
MENTAL DISORDERS
(
)
HYPOTENSION
(
)
FRACTURES AND/OR TRAUMAS DURING THE LAST 60 DAYS ( )
SOME KIND OF OTHER ILLNESS:
SPECIFICATION: HAVE YOU EVER BEEN SUBJECTED TO A MEDICAL OPERATION?
YES
NO
WHAT KIND?
EXPOCYTAR 2017
www.expocytar.com
[email protected]
[email protected] [email protected] Teléfono:+ 54-2954-561887 Móviles: + (549) 2954 - 334983/ 334984
Club de Ciencia y Tecnología AMÚN KAMAPU
Red ArCiTeCo
V Expociencias de Argentina 5, 6 y 7 de Octubre- Santa Rosa – La Pampa
DO YOU HAVE ANY ALLERGIES? If so specify the following:
YES
NO
YES
NO
FOOD: MEDICINES: ENVIRONMENTAL FACTORS: OTHER:
VACCINES DO YOU HAVE A COMPLETE VACCINATIN SCHEDULE? ANTI-TETANUS: YES _ _ / _ _ / _ _ (If so indicate the date of the vaccination.)
NO
INFLUENZA: YES __/__/__ NO (If so indicate the date of the vaccination.)
ARE YOU TAKING ANY MEDICATION?
YES
NO
YES
NO
YES
NO
YES
NO
WHAT KIND? ARE YOU ON ANY PARTICULAR MEDICAL DIET? WHAT KIND? DO YOU SUFFER FROM ANY CONTAGIOUS DISEASE? WHAT KIND? DO YOU SUFFER FROM ANY PHYSICAL DISABBILITY? WHAT KIND? OTHER INFORMATION THAT YOU CONSIDER IMPORTANT:
Place and date: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ -----------------------------------------------------------------Doctor’s signature and explanation
EXPOCYTAR 2017
www.expocytar.com
[email protected]
[email protected] [email protected] Teléfono:+ 54-2954-561887 Móviles: + (549) 2954 - 334983/ 334984
Club de Ciencia y Tecnología AMÚN KAMAPU
Red ArCiTeCo