Historia clinica

Introduction Instructions Terms of Service Patient Identification Data Personal History Personal History (Non-Pathological) Personal History (Pathological) Gynecologic and Obstetric History Review of Systems Physical Examination Previous and Current Laboratory, Imaging, and Other Test Results Treatment and Results (Medication, Route, Dose, Frequency) Diagnosis(es) or Clinical Problems Prognosis Physician Interview

Introduction

Welcome to Kaloni!

Please provide the following information to access your medical history:

Enter your email address

Enter your date of birth

Please complete all information

Introduction

Welcome to Kaloni!

Please take a few minutes to answer your medical history, this will allow us to thoroughly understand your current health to initiate your regenerative medicine treatment. Remember that our treatments and attention are completely personalize according to your answers, so we ask you to answer with complete honesty. Instructions: It is advised to start answering the medical history at a calm moment of your day so you can take your time to look for dates and information required.

1. It is important to answer each of the blocks in this medical history in its entirety. This will allow you to continue with your responses.
2. It is suggested that you use the save button after completing each block. This will allow you to return to where you left off in case you are unable to complete your medical history entirely.
3. If you are unable to complete all the blocks of your medical history, you will be able to re-enter it through the link previously shared with you by providing your email address and date of birth on any device.
4. Use the buttons at the bottom of the screen: “Back” to return to the previous section, “Next” to move to the next section, and “Save” to keep your information for each section.
5. It is suggested to use the “Save” button after completing each section; this will allow you to return to where you left off in case you are unable to complete your medical history in one go.
6. If you did not complete all sections of your medical history, you can re-enter it using the link previously shared with you, by entering your email address and date of birth.

It is very important for us to help you improve your quality of life.

Introduction

Terms of Service

Before using our medical history, please read the terms of service and remember:

The medical history is not for medical emergencies. Please call your local emergency number immediately if you have a medical emergency.
Your data is safe. The information you provide will not be shared to identify you.

I have read and accept the terms of service. *

I agree that information about my health may be used for the medical interview. More information is available in the privacy policy.

Please complete all information

Identification Data Sheet

First Name

Last Name

Phone Number

Email Address

birthdate

Sex Assigned at Birth

Age

Clinic

Please complete all the information.

Personal History

Personal History Select one answer in each row.
Remember to click save to save your progress.

Diabetes

Yes

Arterial Hypertension

Yes

Cardiovascular Conditions

Yes

Other Conditions

Yes

Which?

Cancer

Are there any direct family members with a history of cancer?

Yes

Please specify the type of cancer

Physician's Observations

Por favor, complete toda la información

Personal History (Non-Pathological)

Personal History (Non-Pathological) Select one answer in each row.
Remember to click save to save your progress.

Blood Type

A positive (A+)

B positive (B+)

AB positive (AB+)

O positive (O+)

A negative (A-)

B negative (B-)

AB negative (AB-)

O negative (O-)

I don't remember my blood type

Do you smoke?

Yes

How long have you been smoking?

How many cigarettes do you smoke per day?

Did you use to smoke?

Yes

How long did you smoke?

How many cigarettes did you smoke per day?

Do you consume alcoholic beverages?

Yes

How long have you been drinking alcoholic beverages?

How often do you consume them?

Did you use to consume alcoholic beverages?

Yes

How long did you consume alcoholic beverages?

How often did you consume them?

What hobbies or sports do you practice?

Physician's observations

Por favor, complete toda la información

Personal Medical History

Personal Medical History Select one answer in each row.
Remember to click save to save your progress.

Do you remember the date of your last medical check-up?

I don’t remember the date

Cardiovascular diseases

Have you had a heart attack?

Yes

How many times?

Do you remember when your last heart attack was?

I don’t remember the date

Did you undergo any rehabilitation after your myocardial infarction?

Yes

Describe the improvements observed after your rehabilitation

Do you remember the date of your last echocardiogram?

I don’t remember the date

Do you know your ejection fraction measurement?

Have you ever been diagnosed with carotid artery disease?

Yes

Have you ever suffered from pulmonary embolism?

Yes

Do you currently have any sequelae?

Yes

Describe the sequelae

Hypertension

Do you suffer from Hypertension?

Yes

How many years have you been diagnosed with Hypertension?

Please indicate your treatment

Immunological

Do you have any of the following conditions?

Do you have any unknown immune condition?

Yes

Which one?

HIV

Yes

What is the value of your latest viral load?

What treatment are you using?

Have you been tested for HIV?

Yes

When was your last test?

I do not remember the date

Any other diseases caused by fungi, viruses, or bacteria?

Yes

Which one?

Do you have any post-COVID sequelae?

Yes

Which one?

Respiratory Diseases

Do you have any of these conditions?

Asthma

Yes

Urological Diseases

Do you have any of these conditions?

Do you have any other renal vascular disease?

Yes

Which one?

Do you have any other bladder condition?

Yes

Which one?

Have you experienced any changes in erectile function?

Yes

Liver, Gallbladder, and Pancreatic Diseases

Have you been diagnosed with any of the following diseases?

Fatty liver disease

Yes

Do you have any gallbladder problems?

Yes

Which one?

Do you have gallstones?

Yes

Do you have chronic pancreatitis?

Yes

Do you have any other pancreatic issues?

Yes

What is it?

Gastrointestinal Diseases

Do you have a history of any of these conditions?

Colonoscopy

Yes

Do you remember the date?

I do not remember the date

Gastroscopy?

Yes

Do you remember the date?

I do not remember the date

Skin Diseases

Have you been diagnosed with any of the following conditions?

Atopic Dermatitis

Yes

Contact Dermatitis

Yes

Rosacea

Yes

Do you have any problems with wound healing (e.g., keloid formation or difficulty healing wounds)?

Yes

Musculoskeletal

Do you currently have or have you ever had any disease affecting your bones or muscles?

Yes

Which one?

Do you have any congenital condition affecting any muscle or joint?

Yes

Describe it

Cancer

Have you ever had cancer?

Yes

Specify the type of cancer

If you were cured of cancer, indicate how long ago this occurred

I don't remember the date

Specify the treatments received

Indicate if you have experienced relapses

Yes

Do you remember the date of your relapse?

I don't remember the date

Do you currently have cancer?

Yes

Indicate the current status of your cancer

Do you remember the date of your diagnosis?

I don't remember the date

What stage was the cancer in at the time of diagnosis?

Endocrine

Do you have Diabetes Mellitus (type 1 or 2)?

Yes

Do you suffer from or have you suffered from any cholesterol disorder?

Yes

Have you had any menopause-related problems?

Yes

Have you had any andropause-related problems?

Yes

Psychiatric Conditions

Do you currently suffer from depression?

Yes

Have you previously suffered from depression?

Yes

Do you currently suffer from anxiety?

Yes

Have you previously suffered from anxiety?

Yes

Coagulation Disorders

Do you have any coagulation disorders?

Yes

Please specify the disorder

Have you ever suffered from any form of Anemia?

Yes

Have you suffered from Hemophilia or any blood coagulation disorder?

Yes

Medications

Please list all medications and/or supplements you are currently taking, including dosage if known.

Are you currently undergoing hormone therapy?

Yes

Please specify which one

Are you taking contraceptives?

Yes

Please specify which one

Allergies

Do you have any allergies to medications?

Yes

Do you have any type of allergy?

Yes

What type of allergy do you have?

Please specify the issue related to your allergy

Surgical History

Have you undergone any surgeries?

Yes

What surgeries have you undergone, and how long ago did each occur?

Date of your last surgery

I do not remember the date

Did you experience any complications during any surgery?

Yes

What complication occurred?

Please indicate the type of anesthesia used during your surgeries

Did you have any reactions to the anesthesia?

Yes

Which reaction?

Have you been admitted to any Intensive Care Unit?

Yes

What was the reason for admission?

Physician's observations

Por favor, complete toda la información

Gynecologic and Obstetric History

Gynecologic and Obstetric History Select one answer in each row.
Remember to click save to save your progress.

Have you had pregnancies?

Yes

How many?

Have you had miscarriages?

Yes

How many?

Cause of your miscarriage(s)

Physician's Observations

Por favor, complete toda la información

Review of Systems

Review of Systems Select one answer in each row.
Remember to click save to save your progress.

Musculoskeletal

Do you have any difficulty walking?

Yes

Do you require support from a wheelchair?

Yes

Do you require the use of crutches or a cane?

Yes

Cardiovascular

Do you have any implanted cardiac devices? (pacemaker, defibrillator, others...)

Yes

Do you have any other cardiac issues?

Yes

Which one?

Do you experience any of these symptoms?

Varicose veins in lower extremities

Yes

Digestive System

Abdominal Distension

Yes

Do you have a history of Heartburn?

Yes

Do you have Gastroesophageal Reflux?

Yes

Nervous System

Have you experienced changes or difficulties in speech?

Yes

Do You Experience Tingling Sensation in Arms and Legs?

Yes

Have You Experienced Dizziness?

Yes

Physician Observations

Por favor, complete toda la información

Physical Examination

Physical Examination Select one answer in each row.
Remember to click save to save your progress.

Temperature

ºC

Blood Pressure

mmHg

Heart Rate

bpm

Respiratory Rate

rpm

Height (ft)

Weight (lbs)

lbs

Patient's Constitution

Endomorph

Ectomorph

Mesomorph

Endomesomorphic

Ectomesomorphic

Patient's External Appearance (Condition)

Good

Poor

Fair

Apparent Gender

Male

Female

Apparent Age

years

Relevant Clinical Data:

Head

Neck

Chest

Abdomen

Extremities

Genitals

Physician's Observations

Por favor, complete toda la información

Previous and Current Laboratory

Previous and Current Laboratory Select one answer in each row.
Remember to click save to save your progress.

Do you have medical records that you can send us? (medical opinions, MRI, computer tomography-CT, X-rays, etc.)

Yes

Have you undergone any genetic testing to assess your risk of cancer?

Yes

Did the test indicate a likelihood of developing cancer?

Yes

Have you undergone any genetic testing to assess your risk of any other disease?

Yes

Physician's observations

Por favor, complete toda la información

Therapeutic approach and outcomes achieved (Medication, route, dosage, frequency)

Therapeutic approach and outcomes achieved (Medication, route, dosage, frequency) Please select an option for each row.
Remember to click on save to store your progress.

Physician's observations

Please complete all the information.

Diagnosis or Clinical Problems

Diagnosis or Clinical Problems Please select an option for each row.
Remember to click on Guardar to store your progress.

Physician's Observations

Please complete all the information.

Prognosis

Prognosis Please select an option for each row.
Remember to click on Guardar to store your progress.

Physician's Observations

Please complete all the information.

Thank you for trusting Kaloni!

You have completed the first part of your medical history. You will soon be contacted by the specialist physician handling your case to proceed with the final part of your medical history, the "Interview with the physician."