QUESTIONNAIRE / CUESTIONARIO: 1 ENGLISH / INGLES Please complete this form before going in to see the doctor and hand it to ame The doctor Por for, rellene este impreso antes de entrar en le consulta del mica v eréguela Ant Al méico Forename and family names (in Latin characters): Nombve y apetidas (en tetra latinas Orsrarions. Hows old were you? (Write your age at the tims in the box next to the illness): Orcanciones. — Cudntes afi tenia? (Bscriba en e} cwidredo junto o la enfermedad cudntos aitos tenia): Date of birth (Christian calendar): Day:. . Month: ‘Year Fecia de nacinsento (celendaria cristiono}: Dias Mes! Ai: Address: a wet eames Telephone: Domicitio: Teléfono: Nationality: acess feccsiseieriaseecnce Countey of origin Nacionalidad: ats de donde proviene ‘Years of residence in Spain: OLess than one J More than one {state how many): .. Aris gue eve viviendoen Espa Menosdeauo Mis de uno (indique cudraos: ‘What sort of symptom do you have? Pain Alnjury or burn Olnfection Other Stntoma que motivé la consulta Dolor Golpe 0 quemadura Infeccién Oire. WHERE is 1? Merk the place on the diagram with an arrow gDowbe wo nike? Marque el lsgar en la figura con una flecha WHEN DID IT START? Lessthan: UOnghour One day 4One week QOnemonth One year ({CukNDo suiPsZ0? Mentos de: Un hore: Un dia Una semena — Unimes vache ltbegan: Suddenly Gradually Inicio ‘ibe Gradual Freouence Has this happened te youbefore? INo Yes Peeionicinsn: jhe ha ocurrido mas veres? No vf PROGRESSION! Cie getsworse with ime It stays the same It comes and goes PROGRESIGW: Auimenta. com ef tiempo Se mantiene fxuat Va y viene Do you assaciare iT AINo- Yes (if “yes”, mark with an x in this list): WITH ANYTHING? No Si (en vase ufirmativo marque con un asye e continuaciér): aLoasecssn sean? O Meals UWhen| move QExercise ~~ UNight-time Daytime Emotions Other Comidas Mosinieauus Bjericio Noche Dia Emociones Otro Is teste arias Tar QNo Yas (mark one or more of he tems in the preceding fet with a crle) T WORSE? No Si marque con un céreulo fas opciones anteriores) (SE AGRAVA CON ALCO’ Earlier illnesses Enformedades previas (1 Cataracts Co Eyes [5 Sinusitis (1 Tensils [1 Goitrs Cataraas Vista Sinusitis inigdalos Bosio Toys Thang (beat [stomach [Intestine Quisies Prd Comnage mage Iniestine [Sexual organs [2 Gall bladder TJ haemorthoids (1 Caesarean (Cancer Orgenas sesuttes Vesicuta bidiar Hemorroides Cestirea Cincer Hysterectomy: [21 OFthe womb [16ithe ovary Histerevtomia (vactemienio} De smatria De ovurio am keg [Varicose veins [7 Others Bravo Piers Nerices Otas Waste THE NUMER IN THE Box: Baca 2 ae Bue Deb CEAPRADD: Times admitted to hospital [—] How old were you? [_] Reason for admission Ingresas en hospital {Cutnios aos tenia? Por qué motive? Masi Ts AN IF YOU HAVE, OR HAVE HAD, ANY SERIOUS LINES SERA CON 2m ASA.S1 Ha TD CO TRNE USED ALGLIA DE ESTAS BHPERMARADES: Diabetes High blood pressure Cancer Stomach leer UProlonged fevers Diabetes Hipewaniion Cancer Clcera de estémage Fietires profongadas DHigh cholesterol QhAnaemia Chronic bronchitis A Heart problerns Prolonged diarthoeas Colesteral Anemia Bronquits crbnica Problems de corezin Diarveas prolongadas Contagious diseases: UHepatitis alos UU Tuberculosis others Enjernedades conagiosas: Heputtis SDA Tedercutosis Oras eT WWw.semergen.es.QUESTIONNAIRE / CUESTIONARIO 2 ENGLISH / INGLES Has anyone in your family had one of the diseases in the preceding list? (write the illness next to the relationship) Hay alguien en a famitia que haya tenido alguna de las enfermedades anteriores? (escriba la enfermedad junto a parentesco) OFether: O Mother Padre Madre: Brother or sister: . O Children: Hermanos: Hijas: Paternal grandfather: CO Maternal grandfather: ‘Abuelo paterno: ‘Abuela paterna: Paternal grandmother: Maternal grandmother: ‘Abuelo materno: Abuela materna Social circumstances Historia social ‘Are youDoING 4.08? «NoYes crags? No Sf Do You HAVE MEDICAL iNsURANCE? «NoYes (write the name of the insurance company): Misve secuno wéorco? No Sf fescriba el nombre de la empresa aseguradora): Do YOU HAVE PROBLEMS WATH ANYONE|IN THE FAMILY? Ne GVYes —Didtheyattackyou? ~QNo Yes {TENE PROBLEMAS COW ALGUIEN DE LA FAMILIA? No Sf gle han agredido? No Se Have YOU TRAVELED TO OR FROM ANOTHER COWNTRYINTHE LAST YEAR? No L1Yes (state country): GHA VIAIADO AL I DESDE EL EXTRANIERO EN Bt. TIMO ARO? No Si indique et pat): Allergies: GNe Des skin QMedications OPericilin lodine Alergias: No Piel Medicinas Penicilina Yodo Asthma O Others D Aspirin Anesthesia ‘Asma Otras Aspiring Anestesia Vaccinations (write in the box how old you were when you had the last shot): Vacunas {escriba en el cuadrado a qué edad recibié le itima): C1 Tetanus [1 German measles L_1 Polio CJ Hepatitis 7) tuberculosis (7 others Teétanos Rubéola Poliomietitis Hepatitis Tuberculosis tras ‘Are you taking any medication? (No Yes ff possible, state the active ingredi Complete this section if you are a woman: Rellene lo siguiente si es usted mujer: Date your last period began: Fecha en que comenzé aia mensiracién Toma medicinas? No St (eseriba, sies posible, los prinepios activas mejor queef nombre comercial): ‘At present: .. Actuaimente: Others in the last years... Otras durante e timo ato: Mark with a cross if you use: Sefiale con un aspa si es usted consumidor de: Tobacco DAleohol Sleeping pills A Tranquilizers Other drugs Tabaco Alcohol Somniferos Tranguilicantes Otras drogas How many days does itast?: ..... Number of pregnancies: Number of abortions: 2Cuéntos das te dura?: Nimero de embarazos: Mimero de abortos: Complications in pregnancy or childbirth?: QNo QYes Complicaciones en embarazoso partes: No St Do you use any method of contraception? No Yes (mark which: Pills injections Wilica agin métode anticonceptivo? No St (sehale cual) Pastas Inyectabies U Condoms Oterilization OD Vasectomy Preservativos Ligadura de tompas Vasectomia Diephragm UProvoked abortion Dispasitvo intrauterino Aborto provocado it rather than the trade name): Every how many days does your period come?: {Cada cusntos dias le viene ia regl?: (if you wish to use one of these methods, draw a circle round the box) (Si desea utilizar alguna, rodee el cuadrado con wn ctrculo} ee WwWww.semerden.es.QUESTIONNAIRE / CUESTIONARIO ENGLISH / INGLES LOCALIZACIONES, Motivos de consulta: QAcuts illness Chronic illness HEAD: ChHeadache: Caneca Dolor Convulsions Convulsiones Baas: Deafness Ofbos: Sordera Eyes: QI see near things poorly O08: Veo mal de cerca Oltching Picor Mout Aching molars Boca: Dolor de muelas Thirst Sed Nose: {Obstruction Nae: Obstruccién Tyroat / Neck: O_Lumps / Glands Gancanra!Curuio: ——‘Buttos/Ganglios Difficulty swallowing Molestias al tragar: was: Cough: Putwoves: Tras: Expectoration: Expectoracién: Lack of air: Falta de aire: Pain: Dolor: Wheezing Silbidos LOCATIONS. Reasons for consulting the doctor: Initial consultation Enfermedad aguda Enfermedad crénica Primera consulta Enfermedad vista antes en esta consulta ‘Accident at work D Other accident OPain Fe QHigh = Qlow Accidente laboral Accidente no labora Dolor Fiebre: Ala Baja Olnfection OPerspiration O Trembling Tiredness Infecci6n Sudoracién Temblor Cansancio Poor appetite O Feeling depressed Sleep problems Slimming Falta de apetito Tristeza Trastorno del sueito Adelgazamiento Oincrease in weight Otching Stabbing pain ONumbness Aumento de peso Picor Pinchaco Falia de sensibitided Ocold QHeat / Burning OResh Skin lesions Frio Calor 1 Ardor Enupciones Lesiones en ta piel Contraception Analysis OXrays O Psychological help Anticoncepein Andlisis Radiografia ‘Ayuda psicoldgica U Social help Sexual problem Blood pressure UW Digestive problem ‘Ayuda social Problema sexual Tensidn arterial Problema digestivo Lung problem OHeart Neurological problem —_AProblarn with bones or muscles Problema pulmonar Corazon Problema neuroidgico Problema osteomuscalar O Diabetes DOther Diabetes Otros motivos ‘Complete the following section only if the problem affects a particular part of the body: Sélo sies una enfermedad localizada en alguna parte del cuerpo, rellene lo siguiente: have been here before withthe same problem Dizziness Vertigo Loss of consciousness Mareo Vertigo Pérdida de conacimiento insomnia Drowsiness Insomnio Sommolencia ONeises Pain Discharge Bleeding Ruidos Dolor Supuracion Sangre | see distant things poorly CII see double CII see lights Dl see ‘floaters’ Yeo mal de lejos Veo dobie Veo luces Yeo telilas Gritty feeling Discharge CA Weateriness SensaciGn de arena Supuracién Lagrimeo Aching front teeth Eruption Swelling Dolor de dienes Erupcin Hinchazén Soreness (Bad breath Quemazén Mel aliento OCatarth Bleeding «Things smell strange Moqueo Sangrado Alteracin del ofato OGoitre Coss of voice OQ Disorder of the voice Bocio Afonia Alteracin de ta vor Aways Only with solids Siempre Sélo con slides Ci rtable cough Dry cough Cough with phlegm Por iritacn Sin moco Con moco Oight-coloured CDark-coloured CWith blood Color elaro Color oscuro Consangre Dat night lying down With exercise CAI the time Nocuurna Acostado Con ejercicio Continua When | breathe When | move When | cough Com la respiracién Con el movimiento Con ta tos Noisy breathing Ruidos a espirar www pofizeres: Www.semergen.esQUESTIONNAIRE / CUESTIONARIO 4 ENGLISH / IN Heart: Heartbeat: Fast heartbeat: Always Sometimes During exertion CLA night. Conzén: — Latides: Late deprisa: Siempre Aratos Conelesfuerzo De noche slow heartbeat Palpitations Cd Occasional "thump" or missed beat Tate despacio Palpitaciones Falta de vida Pain: During exertion At rest it spreads down my arm Dolor: Con elesfuerzo Enreposo Se extiende al brazo Where? ... Donde? Pain / Burning: DAlithe time intermittently Worse after eating C2 Better after eat Dolor | Ardor: Continuo Intermitente Enpeora al comer Se ativa al comer Nausea / Vomiting: OFood Blood Like coffee-grounds ‘Nawseas | Vomitos: Alimentos Sangre Posos coma de café Faeces: Constipation Diarrhoea © QWithmucus — QWith blood ‘With worms Heces: —Estrefimiento ———Darvea Con moco Con sangre Con gusanos Colour: Normal Owhite Black Color: Normal Blancas Negras Biapoer: Pain when urinating OJ urinate very frequently: During the day During the night Veen: Dolor al orinar Orino muchas veces: Durante el dfa Por ta noche Blood in urine Ol leak urine: DAny time With exertion Orino sangre Se me escapa ta orn Sin querer Con el esfuerco Very dark urine CO Weak stream of Ql urinate very little Orino muy oscuro Orino con menos fuerza de chorro Orino poco GeNTAIs: Men: Q Abnormal urine Gonimates: Hombres: Alteraciones en ina Problem with the penis: Secretion U Injury Olnitation Alleraciones en el pene: Secrecién Lesion Irritacion C Disorders of the erection: Udo not ejaculate Ci cannot get an erection Crooked erectior Trastornos de la eveccién: No eyacuto No tengo ereccién Se me desvia Ol feel pain Dl ejaculate very early Tengo dolor Suelto el semen muy pronto Women: — Q Abnormal urine Mujeres: Alteraciones en orina Flow: Normal UAbnormal: Colour Amount Vaginal itching Flujo: Normal Alera: Color Cantidad Picor en ta vulva Periods: Date of last period: ‘Age at time of first period Regla: Fecha deta titima regla: Edad de ta primera regla: Normal Abnormal Delayed Early Bleeding between periods Normat Tengo alteraciones: Reiraso Adelanto Sangrado a mitad de la vegla O Painful periods bleed more than usual | bleed less than usual Dolor en a regla Sangro mds de to normat Sangro menos de lo normat Lasts only a few days, How many days?: ..... Lasts many days. How many days?: .. Me dura pocos dias. ;Cudntos? Me dura muchos dias. ¢Cuéntos?: Sexvality: Oli do not achieve orgasm (2 Painful intercourse Sexualidad: No lengo orgasmo Dolor en el coito Dittle sexual appetite C1| have been raped Poco apetto sexual Me han violado Menopause: How old were you when it started?: Menopausia: Edad ala que aparecié: Ihave the following QPerspiration C1Vaginal itching Qi Problems with my bones symptoms: Suores Picor vaginal Problemas en los huesos ‘Tengo sthloosan, CBlood-stain O Feeling of suffocation Mancho de sangre Sofocos Less: Varicose veins swollen ankles Pain after walking a litle distance Piews: ——Varices Hinchazbn de tbillos Dolor después de cuminar wn rato Heaviness Cramps Numbness Pesadee Calambres ierdo sensibilidad www _pfizer.es www.semergen.