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HEALTH RECORD FOR FOREIG ATIOALS

Most people arriving from another country have problems communicating in the host language, atleast initially. As the doctor needs to know your background in order to offer you the best possible care,

we ask you to answer these questions, in other words to complete your health record and return it to

your doctor.

FULL NAME:........................................................................TODAY'S DATE..................

GENDER: Male O Female O

PASSPORT or ID CARD No:........................... Date of arrival in Spain: .........................................

Date of birth:.................Place of birth (locality and country):.............................................................

Current address: Street....................................... N.............. Locality .........................Tel..................

Reason for immigration: Asylum O, To join relatives O, Economic O, Student O,

OtherO (please specify) ..

Marital status: Single O, Married O, Separated/Divorced O, Widowed OCountries visited before arrival in Spain:..............................................................................................

Date of last residence in your own country:.........................................................................................

Please answer the questions below in order to provide data on your health. Please tick the appropriate

circles.

PRIOR HEALTH RECORD1-Are you allergic to any medicines or substances? Yes O No O

State which

products..................................................................................................................................

Main health problems2- Do you suffer from any illness(es)?

Yes O Which?...............................................................................................................

......................................................................................................................................................

No O3-Have you ever had or do you have any infectious or contagious illness?

Tuberculosis...............Yes O No O

Hepatitis....................Yes O No O

AIDS/HIV.................Yes O No O

Malaria. Yes O No O

Syphilis.....................Yes O No O

Parasitosis.................Yes O No O

Others (please specify)................................................................................................................

4-Have you ever had or do you have any psychiatric illness?

Yes O Please specify.........................................................................................................................

No O

5-Have you ever been operated?

Yes O for what?..............................................................................................................................No O

6-What medicines are you currently taking? ...........................................................................................

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Family planning/ Gynaecology/obstetrics

7-Are you pregnant? No O Yes O Date of most recent period:........................................8-Do you use contraception? No O Yes O What type?:

Condom O, Vasectomy O, Tying tubes O, IUD O, Pill O, Vaginal ring OInjection O, Patch O, Spermicide cream O, Diaphragm O , Withdrawal O, Base temperature O,

Cervical mucus O, Douche O, Rhythm method O

9- Menopause Yes O Date...............Have you had post-menopausal bleeding? S O, No ONo O

10-Number of children ...........Number of abortions Number of stillbirths ........11- Do you have breast examinations? Yes O, No O . Date of latest....................

12- Do you have vaginal cytology checks? S O, No O Date of latest...................

Lifestyle

13-Do you take exercise (minimum: 30 minutes, 3 days a week)?...............................Yes O No O14-Do you smoke (Have you consumed tobacco every day during the last month?)...Yes O No O

15-Do you drink alcohol every day?.............................................................................Yes O No O

16-Do you take any other type of drugs?......................................................................Yes O No O

Which?..................................................................................

Vaccinations

17-Did you receive all the regulatory vaccinations as a child?...........................Yes O No O

(please attach a photocopy of your vaccination calendar if you have it or can obtain it)

Cultural and educational data

18-Your educational level:............................. Illiterate O, Primary O , Secondary O, University O19-Your knowledge of Spanish: None O, I speak a little O, I speak it well O, I write it O

20-What is your religion?:.................................................

Economic data

21-Work situation: Self-employed O, Long-term contract O, Temporary contract O, Unemployed

receiving benefit O, Unemployed (no benefit) O, Housewife O, Retired O, OtherO:...........................

22-Income:........ None O, Under 599 Euros O, Over 599 Euros O

23-Type of employment:.......... Domestic service O, Catering O, Construction O, Agriculture O,Commerce O, Liberal profession O, Prostitution O, OtherO...........................................................

24-Housing: Own home O Rented O Lodgings O Homeless ONumber of rooms....................

Number of people in accommodation unit..................

25-Do you live ? : Alone O, With partnerO, With partner and children O, With other relatives O,

With friends O, OtherO......................................................................................................................