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La alianza de salud para su empresa Millennium Park Plaza, #15 Second ST, Suite 540 Guaynabo, PR 00968 787-708-6777 Fax 787-708-6779 www.prevencionpr.com
Estimado/a Ejecutivo/a: Quiero darle la más cordial Bienvenida al Mundo de Wellness Alliance. Wellness Alliance es una empresa orientada al servicio al cliente, con un enfoque integrador y multidisciplinario de la Medicina Ocupacional y Preventiva. Le aseguramos servicios de Salud de calidad orientados al mejoramiento del cuerpo, mente y espíritu de la fuerza laboral en Puerto Rico, mientras desarrolla alianzas corporativas con las diferentes Compañías Nacionales e Internacionales. Nuestro personal está preparado para asegurar que su evaluación sea completada con rapidez y profesionalismo. Durante su visita experimentará un servicio de primera calidad, con un toque personal y exclusivo en el mejor ambiente. Le invitamos a relajarse y disfrutar de la experiencia Boutique Medicine en Wellness Alliance. Cordialmente, Angel L. Soto MD Director Médico Wellness Alliance
Instrucciones Generales
Para coordinar su cita puede hacerlo a su conveniencia: a. Llamando al 787-708-6777, 787-708-6778 ó 787-567-3607 b. Enviando correo electrónico a [email protected]
Una vez coordinada la cita se le confirmará la misma por correo electrónico. Debe llenar los documentos y enviarlos antes de su cita. Si tiene menos de 32 años no tiene que completar el cuestionario Coronary Risk Profile.
Su tiempo es valioso por lo que hemos reservado y personalizado su cita. Si por alguna razón no puede asistir a su cita, por favor, avísenos con por lo menos 24 horas de anticipación.
Para que el programa Wellness Care Platinum funcione de la manera más eficiente, su cita se programa para la fecha y hora indicada. Su puntualidad es indispensable. Debe presentarse a partir de las 7:00 am y no más tarde del las 8:00 am.
Estamos localizados en Metro Office Park, Edif. Millennium Park Plaza # 15, Second Street, Suite 540, Guaynabo.
Traiga su tarjeta de identificación de su Plan Médico o la autorización de la empresa para la cual labora, si aplica.
Si nos visita por segunda ocasión, recuerde traer su “pendrive” para actualizarlo con los resultados de su evaluación.
Use ropa y zapatos cómodos, especialmente porque se efectuará una prueba de ejercicio (stress test). Para esta prueba las damas deben utilizar “Sport Bra” para su conveniencia.
El día del examen debe estar en ayuna desde las 12:00 de la medianoche. (No tome alimentos ni bebidas después de las 12:00 a.m.)
Traiga sus medicamentos recetados para que los tome cuando se le indique.
Tómese una muestra de excreta el día antes de la evaluación en el envase provisto. Para esto no se necesita preparación especial alguna, luego échela dentro de una bolsa plástica con cierre (ziploc) e identifíquela con su nombre. El envase para esta prueba puede recogerlo en el área de enfermería de su empresa.
Prueba de Sonografía. Debe estar en ayuna. El sonograma pélvico de las damas requiere tomar mucha agua.
A los caballeros mayores de 40 años se le realizará la prueba de PSA sanguíneo y un examen rectal.
Para su seguridad y debido a la exposición de radiación, no se realizará la placa de pecho a las féminas que estén embarazadas o sospechen estarlo, o si están lactando.
Si tiene preguntas o dudas, o necesita información adicional, llámenos al 787-708-6777 ó 787-708-6778.
La alianza de salud para su empresa
Millennium Park Plaza, #15 Second ST, suite 540 Guaynabo, PR 00968 PO Box 9419 San Juan, Puerto Rico, 00908
www.wellnessalliancepr.com
Breakfast Menu for ____________ Favor escoger una de las siguientes alternativas / Please choose one of the following:
Alternativa 1 /Alternative 1 Tortilla (sin colesterol) / Omelet (Cholesterol Free)
Jamón (99% libre de grasa) / Ham (99% Fat free)
Queso (libre de grasa) . Cheese (Fat Free)
Cebolla / Onion
Pimientos / Pepper
Alternativa 2 / Alternative 2 Cereal / Cereal Ambas alternativas con:
Frutas /Fruits
Café / Coffee Chocolate caliente / Hot Chocolate or Té /Tea
Jugo de china / Orange Juice
La alianza de salud para su empresa
Millennium Park Plaza, #15 Second ST, suite 540 Guaynabo, PR 00968 PO Box 9419 San Juan, Puerto Rico, 00908
www.wellnessalliancepr.com
CONSENTIMIENTO / CONSENT
WELLNESS CARE PLATINUM
Yo ______________________________________ autorizo a Wellness Alliance a realizar
las siguientes pruebas como parte de la Evaluación Preventiva Anual. /
I _________________________________________ authorize Wellness Alliance to perform
the following tests as part of the Annual Preventive Evaluation.
Laboratorios/Laboratories
Evaluación de Próstata (hombres mayores de 40 años) con PSA / Prostate
Assessment (male > 40 years old)
Prueba de Esfuerzo Cardiovascular (Stress Test) /Cardiovascular Stress Test
Sonograma Abdominal / Abdominal Sonogram
Sonograma Pélvico (solo mujeres) / Pelvic Sonogram
Placa de Pecho / Chest X Ray
Cernimiento Audivito / Hearing Screening
Cernimiento Visual / Visual Screening
Espirometria (Función Pulmonar) / Spirometry (Pulmonary function Test)
Cernimiento de Salud Mental / Mental Health Screening
Cernimiento Nutricional/Nutritional Screening
Perfil de Riesgo Coronario / Coronary Risk Profile
Examen Físico – Physical Examination
Certifico que se me entregó y leí la Ley de Privacidad del Paciente, conocida por sus
abreviaturas, Ley HIPPA. / I certify that I received and read the Patient Privacy Act,
known by its initials, HIPAA Law.
___________________________________________________________________
Firma Fecha
INFORMACION PERSONAL PERSONAL INFORMATION
_______________________________________________________________________________________________________
APELLIDO PATERNO / LAST NAME MATERNO / MAIDEN NOMBRE / NAME INICIAL / INITIAL
Sexo/Sex ⃝ Femenino / Female ⃝ Masculino / Male Estado civil / Marital Status ____________
Fecha de Nacimiento /Date of birth Dia/Date _____ Mes/Month ____ Año / Year __________
Raza / Race ⃝ Blanca / White ⃝ Negra / black ⃝ Otra / Other
Religión / Religion _______________________ Etnicidad / Ethnicity : ⃝ Hispano ⃝ No hispano
Teléfono Residencial / Home Phone ( ) ___________________________
Teléfono Trabajo / Work Phone ( ) ___________________________
Celular / Cellular ( ) ___________________________
Correo Electrónico / Email address ______________________________________________________________
Empleador / Employer _________________________________________
Dirección Postal / Postal Address ______________________________________________________________
____________________________________________________________________________________________
Ciudad/City ____________________ Estado / State _________ Area Postal/ Zip Code __________________
Dirección Física / Physical Address (if different) _________________________________________________
____________________________________________________________________________________________
Ciudad/City ____________________ Estado / State _________ Area Postal/ Zip Code __________________
Contacto en caso de emergencia/ Contact in case of emergency ____________________________________
Relación / Relation __________________________________________________________________________
Teléfono / Telephone ( ) _______________________________
PLAN MEDICO/HEALTH INSURANCE
Plan Primario / Primary Plan ⃝ SSS ⃝ MCS ⃝ HUMANA ⃝ MAPFRE ⃝ OTRO: ________________
Asegurado principal / Primary assured __________________________________________________________
Relación con el paciente / relation with patient _________________________________________________
Plan Secundario / Secondary Plan ⃝ SSS ⃝ MCS ⃝ HUMANA ⃝ MAPFRE ⃝ OTRO: ____________
Asegurado principal / Primary assured __________________________________________________________
Relación con el paciente / relation with patient __________________________________________________
RESUMEN DE HISTORIAL MÉDICO MEDICAL HISTORY SUMMARY
APELLIDOS/
Last Name
NOMBRE
NAME
FECHA DATE
Por favor, marque los encasillados de aquellas condiciones o enfermedades que ha padecido o que padece en el presente. Please, make a mark on the boxes for those conditions or illnesses you have suffered.
Dolor de cabeza frecuente / Frequent headaches
Fractura de cráneo / Skull Fracture
Pérdida del conocimiento / Loss of consciousness
Pérdida de memoria / Memory loss
Convulsiones / Seizures
Visión doble / Double vision
Ardor en la vista / Burning sensation in the eyes
Lagrimación frecuente / Frequent lacrimation
Irritación en los ojos / Eye irritation
Infecciones de oído frecuentes / Frequent ear infections
Pérdida de audición / Hearing loss
Silbido en los oídos / Ringing in the ears
Alergia nasal / Nasal allergy
Sangrado nasal frecuente / Frequent nasal bleeding
Sinusitis frecuente / Frequent sinusitis
Mareos frecuentes / Frequent dizziness
Hipertiroidismo / Hyperthyroidism
Hipotiroidismo / Hypothyroidism
Asma / Asthma
Bronquitis / Bronchitis
Tuberculosis
Pulmonía / Pneumonia
Tos persistente / Persistent coughing
Flema con sangre / Phlegm with blood
Falta de aire / Shortness of breath
Fatiga durante la noche / Nocturnal fatigue
Palpitaciones / Palpitations
Dolor de pecho / Chest pain
Infarto cardiaco / Myocardial infarction
Hernia en el esófago / Esophageal hernia
Úlceras estomacales / Gastric ulcers
Úlcera duodenal / Duodenal ulcer
Náuseas o vómitos frecuentes / Frequent nausea or vomiting
Vómito con sangre / Blood vomiting
Dolor abdominal frecuente / Frequent abdominal pain
Ictericia (piel amarilla) / Jaundice (yellow skin)
Lesiones en la piel / Skin lesions
Hepatitis
Piedras en la vesícula / Gallbladder stones
Pancreatitis
Divertículos / Diverticulosis
Hemorroides / Hemorrhoids
Estreñimiento / Constipation
Diarrea frecuente / Frequent diarrhea
Sangre en la excreta / Blood in feces
Hernia inguinal / Inguinal Hernia
Hernia abdominal / Abdominal hernia
Masas en el cuello / Neck masses
Nódulos agrandados / Enlarged nodules
Ronquera frecuente / Frequent voice hoarseness
Infecciones de garganta / Throat infections
Problemas con las encías / Gum problems
Infecciones de orina / Urinary infections
Cistitis frecuente / Frequent cystitis
Infecciones en los riñones / Kidney infections
Piedras en los riñones / Kidney stones
Sangre en la orina / Blood in urine
Agrandamiento de la próstata / Prostate enlargement
Infecciones de la próstata / Prostate infections
Infecciones venéreas / Venereal infections
Disminución en el flujo de orina / Decreased urinary stream
Coyunturas dolorosas / Painful joints
Dolor en los brazos / Pain in the arm
Dolor en las piernas / Leg pain
Adormecimiento de los pies / Feet numbness
Adormecimiento de las piernas / Leg numbness
Adormecimiento de las manos / Hand numbness
Flebitis / Phlebitis
Dolor de espalda / Back pain
Discos herniados / Vertebral disk herniation
Calambres nocturnos / Nocturnal cramps
Venas varicosas / Varicose veins
Problemas de circulación / Circulatory problems
Transfusiones de sangre / Blood transfusions
Anemia
Presión sanguínea alta / High blood pressure
Diabetes, desde cuándo: / Diabetes, since when:
Colesterol elevado / High cholesterol
Triglicéridos elevados / Increased triglycerides
Ácido úrico elevado /High uric acid
Sobrepeso sobre 15 libras / Overweight more than 15 lbs.
Pérdida de peso anormal / Abnormal weight loss
Hace ejercicio regularmente / Exercise regularly
Pérdida de apetito / Loss of appetite
Fiebre recurrente / Recurrent fever
Fiebre nocturna / Nocturnal fever
Sudores nocturno / Night sweat
Fuma, desde cuando: ; cuántos al día:
Smoke, since when: ; how many a day:
Consume alcohol, cuántos tragos semanales:
Alcohol consumption; how many drinks a week:
RESUMEN DE HISTORIAL MÉDICO (Continuación) MEDICAL HISTORY SUMMARY (Continuation)
Alergias a alimentos / Food allergies: Alergias a medicamentos / Drug allergies:
Cirugías / Surgeries: Medicamentos que está tomando / Current medication:
HISTORIAL FAMILIAR / FAMILY HISTORY
Muerte súbita / Sudden death
Infarto cardiaco / Cardiac infarction
Presión sanguínea alta / Blood high pressure
Diabetes
Cáncer de seno / Breast cancer
Cáncer del colon; Colon cancer
Cáncer de la próstata / Prostate cancer
Tuberculosis
Otro, especifique:
Other, specify:
HISTORIAL DE VACUNACIÓN / IMMUNIZATION HISTORY
Pulmonía / Pneumonia
Influenza
Tétano / Tetanus
Sarampión / Measles
Varicela / Chicken pox
Papera / Mumps
Hepatitis: ¿cuál? A B
Otro, especifique:
Other, specify:
SÓLO PARA FÉMINAS / FOR FEMALES ONLY
Dolor en los senos / Breast Pain Raspes / Dilation & Curettage (D&C)
Masas en los senos / Breast masses Cirugía de la útero / Uterine surgery
Cirugía o biopsia de seno / Breast surgery or biopsy Cirugía de los ovarios / Ovarian surgery
Menstruación normal / Normal menstruation Toma suplementos de calcio / Take calcium supplements
Menstruación dolorosa / Painful menstruation Toma reemplazo hormonal / Take hormonal substitute. ¿Cuál? / Which one? Menstruación prolongada / Prolonged menstruation
Colonoscopía / Colonoscopy Fecha/Date
Número de embarazos / Number of pregnancies: Número de partos / Number of deliveries:
Número de abortos / Number of abortions: Número de cesáreas / Number of C-sections:
Última menstruación / Last menstrual period: Última mamografía / Last mammogram: Fecha / Date:
SÓLO PARA VARONES / FOR MEN ONLY
Examen rectal de la próstata / Rectal prostate exam: Fecha / Date:
Colonoscopía / Colonoscopy: Fecha / Date:
Perfil de Riesgo Coronario / Coronary Risk Profile Página / Page 1
PERFIL DE RIESGO CORONARIO / CORONARY RISK PROFILE Por favor, escriba en letra de molde. / PLEASE PRINT
Apellidos Last Name(s)
Nombre Name
Inicial Middle Initial
Fecha De Nacimiento Date of Birth
Sexo Gender
M F Peso Weight
Estatura Height
Raza Race
Caucásica / White Afro-americana / African-American Hispano / Hispanic
Asiático / Asian Nativo americano / Native American Otro / Other:
Dirección
Ciudad City
Estado State
Código Postal Zip Code
# Teléfono del Hogar Home Telephone #
# Teléfono del Trabajo Work Telephone #
Dirección De Correo Electrónico E-Mail Address
HISTORIAL DE SALUD / HEALTH HISTORY
Familiar / Family: Haga una marca en cualquier problema de salud que ha tenido su familia (padre, madres, hermano o hermana). Make a mark on any health problems found in your family (father, mother, brother or sister)
Diabetes
Infarto antes de los 65 años de edad Stroke before the age of 65
Enfermedad coronaria, infarto cardiaco o cirugía coronaria antes de los 55 años de edad para varones, 65 años de edad para las féminas Coronary heart disease, heart attack or coronary surgery before the age of 55 for men, 65 for women
Obesidad / Obesity
Colesterol alto / High cholesterol Presión arterial alta / High blood pressure
Historial de Salud Personal / Personal Health History: Haga una marca en cualquier problema de salud que su médico le haya dicho que tiene. / Make a mark on any health problem your physician has told you that you have.
Enfermedad coronaria, angina (dolor de pecho), ataque cardiaco, cirugía coronaria de desviación arterial, marcapasos, desfibrilador, colocación de stent, o angioplastia
Coronary heart disease, angina (chest pain), a heart attack, coronary artery bypass surgery, pacemaker, defibrillator, stent placement or angioplasty
Fallo cardiaco congestivo Congestive heart failure
Arritmia (latidos rápidos e irregulares del corazón Atrial fibrillation (rapid, irregular heartbeat)
Síncope o flujo sanguíneo restringido a la cabeza Stroke or restricted blood flow to head
Ataques isquémicos pasajeros (señales de aviso de síncope) Transient ischemic attack (stroke warning signs)
Dolor en la pantorrilla mientras camina que cesa con descanso Pain in calf when walking that stops with rest
Colesterol sanguíneo alto (240+ mg/dL o 6.2 mmol/L) High blood cholesterol (240+ mg/dL o 6.2 mmol/L)
Presión arterial alta (140/90+) High blood pressure (140/90+)
Diabetes Diabetes
Bronquitis crónica o enfisema (COPD) Chronic bronchitis or emphysema (COPD)
Tos crónica (3 semanas o más) Chronic cough (3 weeks or more)
Asma (jadeo, tos, dificultad para respirar) Asthma (wheezing, coughing, difficulty breathing)
Corto de respiración al ejercitarse Shortness of breath with exertion
Medicamentos / Medications. Marque cualesquiera medicinas que toma regularmente. / Mark any medicines you take regularly.
Nitroglicerina, para el dolor de pecho / Nitroglycerine, for chest pain Medicina para la presión alta / Blood pressure medicine
Aspirina / Aspirin Anticoagulante (diluyente sanguíneo) / Anticoagulant (blood thinner)
Medicina para bajar el colesterol / Cholesterol-lowering medicine Medicina para la Diabetes / Diabetes medicine
Estrógeno, hormonas femeninas / Estrogen, feminine hormones Medicina para el asma, COPD / Asthma, COPD medicine
Otro / Other:
Historial de Fumador / Smoking History Indique sus prácticas actuales de fumador / Indicate your present smoking practices.
Nunca ha fumado / Never smoked Dejó de fumar hace más de un año / Quit smoking more than a year ago
Fuma cigarrillos actualmente / Currently smoke cigarettes Dejó de fumar durante el pasado año / Quit smoking within the last year
Fuma una pipa o cigarro solamente / Smoke a pipe or cigar only
Fumador de segunda mano / Secondhand smoke: ¿Está usted expuesto a humo de segunda mano regularmente en el hogar o en el trabajo? Sí No Are ;you exposed to secondhand smoke regularly at home or at work? Yes No
Actividad Física / Physical Activity
Ejercicio aeróbico: ¿Cuántas días a la semana acumula usted por lo menos 30
minutos de actividad física como caminar ligero, ciclismo, trotar, nadar, jardinería activa o deportes activos?
Aerobic exercise: How many days each week do you accumulate at least 30
minutes of physical activity such as brisk walking, cycling, jogging, swimming, active gardening or active sports?
Ningún ejercicio regular Un día Dos días No regular exercise One Two
De tres a cuatro días Cinco días Three to four Five or more
Actividades moderadas: ¿Cuánto tiempo pasa usted semanalmente en actividades
moderadas (caminar ligero, correr bicicleta hasta 10 mph, baile aeróbico, etc.)? Moderate Activities.: How much time each week do you spend doing moderate
activities (e.g. brisk walking, bike up to10 mph, aerobic dance)?
Ninguna actividad regular ½ hora 1 hora No regular activity ½ hour 1 hour
2 horas 3-4 horas 5 horas o más 2 hours 3-4 hours 5 or more hours
Actividades vigorosas: ¿Cuánto tiempo pasa usted semanalmente en actividades
vigorosas (correr, correr bicicleta hasta 12 mph o más, deportes activos)? Vigorous Activities.: How much time each week do you spend doing vigorous
activities (e.g. running, bike up to12 or more mph, active sports)?
Ninguna actividad regular ½ hora 1 hora No regular activity ½ hour 1 hour
2 horas 3-4 horas 5 horas o más 2 hours 3-4 hours 5 or more hours
Perfil de Riesgo Coronario / Coronary Risk Profile Página / Page 2
Restricción de ejercicio. ¿Le ha restringido un médico la actividad por razones de salud? Sí No
Exercise Restriction. Has a doctor restricted your activity for health reasons? Yes No
Hábitos alimenticios / Eating Practices
Comidas regulares.
¿Omite el desayuno u otras comidas regularmente? Sí No
Regular meals. Do you often skip breakfast or other meals? Yes No
Panes/granos. ¿Cuántas porciones de panes o cereales integrales consume usted diariamente (porción = 1 rebanada de pan; 1 taza de cereal seco; ½ taza de cereal cocido; ½ taza de arroz integral)?
Breads/Grains. How many servings of whole grain bread or cereals do you eat daily
(serving = 1 slice bread; 1 cup dry cereal; ½ cup cooked cereal; ½ cup of brown rice?
Ninguna Una Dos Tres Cuatro 5 o más None One Two Three Four 5 or more
Frutas. ¿Cuántas porciones de frutas consume usted diariamente (porción = 1 taza
fresca; ½ taza cocidas; 6 onzas de jugo)? Fruits. How many servings of fruits do you eat daily (serving = 1 cup fresh; ½ cup
cooked; 6 oz of juice?
Ninguna Una Dos Tres Cuatro o más None One Two Three Four or more
Vegetales. ¿Cuántas porciones de vegetales consume usted diariamente (porción =
1 taza crudos; ½ taza cocidos; 6 onzas de jugo de vegetales; 1 ensalada mediana)? Vegetables. How many servings of vegetables do you eat daily (serving = 1 cup raw;
½ cup cooked; 6 oz of vegetable juice; 1 medium salad)?
Ninguna Una Dos Tres Cuatro 5 o más None One Two Three Four 5 or more
Alimentos refinados. ¿Cuántas veces al día consume usted alimentos altamente
refinados y meriendas típicas (bebidas carbonatadas, chips, papitas fritas, postres, galletas, bizcocho u otros dulces)?
Refined Foods. How times a day do you eat highly refined foods and typical snacks
(soda pop, chips, fries, pastry, cookies, cake or other sweets)?
Ninguna Una Dos Tres Cuatro 5 o más None One Two Three Four 5 or more
Grasas. Marque cualquiera de las siguientes grasas o alimentos altos en grasas que
usted típicamente consume (incluyendo los que usa al cocinar). Fats. Mark any of the fats or high fat foods below that you typically eat (including
those used in cooking?
Mantequilla Margarina en barra Margarina libre de ácidos trans-grasos Aderezo para ensalada en aceite o mayonesa Aceites vegetales (i.e., oliva, canola, soya) Manteca o jugo de la carne Nueces, semillas o mantequilla no hidrogenada de maní Aceitunas o aguacate
Butter Stick margarine Trans fatty acid free margarine Oil-based salad dressing or mayonnaise Vegetable oils (e.g., olive, canola, soy) Shortening, lard or meat drippings Nuts, seeds or non-hydrogenated nut butters Olives or avocados
Carnes. ¿Qué clase de carne consume usted usualmente? Meats. What type of meat do you usually eat?
Carnes rojas mayormente incluyendo bistec, hamburguesa, hot dog, tocineta, salchichas o pollo frito.
Primarily read meats including steak, hamburger, hot dog, bacon, sausage or fried chicken
Rara vez carne roja o limitado a cortes magros, o come pollo sin piel o pescado Seldom eat red meat or limit it to only lean cuts, or eat skinless poultry or fish
Rara vez come carne, come alimentos mayormente sin carne (alimentos vegetarianos de proteína)
Seldom each any meats, eat primarily meatless entrees (vegetarian protein foods)
Huevos. ¿Cuántas yemas de huevo consume usted semanalmente (incluyendo las que usa al cocinar)?
Eggs. How many egg yolks do you each week (including those used in cooking)?
Ninguna Una Dos Tres Cuatro 5 o más None One Two Three Four 5 or more
Nueces y semillas. ¿Cuántas porciones de nueces, semillas o mantequilla no hidrogenada de maní consume usted semanalmente (1 porción = 1 oz de nueces o
semillas o 2 cucharadas de mantequilla de nueces)?
Nuts and Seeds. How many servings of nuts, seeds or non-hydrogenated nut butters do you eat weekly (serving = 1 oz of nuts or seeds, o 2 tablespoons of nut butter)?
Ninguna Una Dos Tres Cuatro 5 o más None One Two Three Four 5 or more
Productos lácteos. ¿Qué clase de productos lácteos usa usted usualmente? Dairy Products. What type of dairy products do you usually use?
leche regular, yogur, queso, crema agria
solamente productos lácteos sin grasa (o no lácteos)
consumo ambos
regular milk, yogurt, cheese, sour cream
only non-fat dairy products (or non-dairy
use both of the above
Legumbres. ¿Cuántas porciones (2/3 de taza) de habichuelas, guisantes o habichuelas de soya consume usted semanalmente?
Legumes. How may servings (2/3 cup) of beans, split peas or soybeans do you eat weekly?
Ninguna o menos de 1 1 ó 2 3 o más None or less than one 1 or 2 3 or more
Sal. ¿Añade usted a menudo sal a su comida en la mesa o come alimentos salados
(pepinillos, salsa soya, papitas) frecuentemente? Sí No
Salt. Do you often add salt to your food at the table and frequently eat salty foods
(pickles, soy sauce, chips)? Yes No
Bebidas con cafeína. ¿Cuántas bebidas con cafeína toma usted diariamente (café, té, colas)?
Caffeine Drinks. How many caffeinated beverages do you drink daily (coffee, tea, cola drinks)?
Ninguna Una Dos Tres Cuatro 5 o más None One Two Three Four 5 or more
Agua. ¿Cuántos vasos de agua toma usted diariamente? Water. How many glasses of water do you drink daily?
Menos de 3 3 a 5 6 a 7 8 o más Less than 3 3 to 5 6 to 7 8 or more
Comidas de restaurantes.
Cuando come afuera, ¿qué tipo de comidas ordena usted típicamente? Comidas altas en grasa: establecimientos de comida rápida, biftec, pollo frito, alimentos con salsas espesas, crema agria, queso, y postres suculentos O comidas más saludables: bajas en grasa y más vegetales, granos y frutas
Restaurant Meals. When you eat out, what type of meals do you typically order? High fat meals: fast food, steak, fried chicken, foods with rich sauces, sour cream, cheese, and rich desserts Or healthier meals: lower in fat and more vegetables, grains, and fruits
mayormente comidas altas en grasas
mayormente comidas más saludables o rara vez como afuera
como más o menos la misma cantidad de ambas
mostly high fat meals
mostly healthier meals or seldom eat out
eat both kinds about the same
Alcohol. ¿Cuántos bebidas alcohólicas toma usted en una semana?
(1 trago = 12 oz de cerveza, 5.5 oz de vino o 1.5 oz de licor)?
Alcohol. How many alcohol containing beverages do you drink in a typical week?
(1 drink = 12 oz of beer, 5.5 oz of wine or 1.5 of liquor)
rara vez o nunca tomo esas bebidas hasta 7 hasta 14 más de 14 rarely drink these beverages up to 7 up to 14 more than 14
Peso. Indique cualquier cambio de peso desde que tenía 21 años de edad
No he subido de peso o he aumentado menos de10 libras.
He aumentado de 10 a 19 libras.
He aumentado de 20 a 29 libras.
He aumentado de 30 libras o más.
Weight. Indicate any change in weight since you were about 21 years old.
I have not gained weight or gained less tan 10 pounds.
I have gained 10 to 19 pounds.
I have gained 20 to 29 pounds.
I have gained 30 pounds or more.
Perfil de Riesgo Coronario / Coronary Risk Profile Página / Page 3
Factores Mentales y Sociales / Mental and Social Factors
Las emociones y relaciones pueden tener un efecto sobre la salud cardiaca. Indique su situación. Emotions and relationships can have an effect on heart health. Indicate your situation.
Triste. ¿Se ha sentido triste e infeliz gran parte del tiempo
últimamente? Sí No Unhappy. Have you felt sad and unhappy much of the time lately? Yes No
Coraje. ¿Se ha sentido frustrado, molesto o con coraje gran parte del tiempo últimamente?
Sí No Anger. Have you felt frustrated, upset or angry much of the time lately?
Yes No
Apoyo social. ¿Tiene usted familiares o amigos a quienes les habla y con quienes socializa frecuentemente?
Sí No Social Support. Do you have family and friends you talk to and socialize with frequently?
Yes No
Comunidad. ¿Se reúne usted regularmente con un grupo que le da apoyo, alivio y significado en su vida?
Sí No Community. Do you meet regularly with a group that give you support, comfort, and meaning in your life?
Yes No
Sueño. ¿Duerme por lo general menos de 7 a 8 horas diariamente? Sí No Sleep. Do you usually get less than 7 to 8 hours of sleep daily? Yes No
Agotamiento. ¿Se siente usted cansado, agotado y exhausto gran parte del tiempo?
Sí No Fatigue. Do you feel tired, worn out, and exhausted much of the time?
Yes No
Mujeres solamente. Marque cualquier condición que aplique.
Actualmente embarazada Llegué a la menopausia.
Women only. Mark any condition that applies.
Currently pregnant Reached menopause
Preparación. ¿Está usted preparado para hacer cambios de estilo de vida para mejorar su salud en las siguientes áreas?
(Refiérase a las cinco descripciones listadas.)
1 Ningún interés actual en hacer cualquier cambio de estilo de vida 2 Considerando hacer un cambio de estilo de vida 3 Haciendo planes para lograr este cambio 4 Comencé recientemente a implementar este cambio. 5 Lo he estado haciendo por 6 meses o más.
Readiness. Are you ready to make lifestyle changes to improve your health in the following areas?
(Refer to the five descriptions shown.)
1 No present interest in making any lifestyle change 2 Thinking about making a lifestyle changes 3 Making plants to achieve this change 4 Recently started implementing this change. 5 Have been doing this for 6 months or more.
1 2 3 4 5 Comer diariamente alimentos saludables para el corazón 1 2 3 4 5 Eat heart-healthy meals daily
1 2 3 4 5 Dejar de fumar o continuar siendo un no fumador 1 2 3 4 5 Quit smoking or remain a non-smoker
1 2 3 4 5 30 minutos o más de actividad física, 3-4 + días a la semana 1 2 3 4 5 30 minutes or more of physical activity, 3-4+ days/per week
1 2 3 4 5 Lograr/mantener un peso saludable 1 2 3 4 5 Achieve/maintain a healthy weight
Fecha / Date:
La alianza de salud para su empresa
Millennium Park Plaza, #15 Second ST, suite 540 Guaynabo, PR 00968-1743 787-708-6777
www.prevencionpr.com
AUTORIZACION
Yo, _______________________, autorizo a Wellness Alliance a
enviar los resultados de la evaluación médica preventiva al correo
electrónico ___________________________________ de darse
alguna de las siguientes situaciones:
Resultados alterados que requieren atención inmediata
No poder asistir a mi cita de Entrevista Final luego de ser contactado
por el personal de Wellness Alliance
De no recibir contestación para coordinar su entrevista final luego de
ser contactado en más de tres ocasiones.
______________________ ______________
Firma Fecha
Número Récord: _________________
De no tener correo electrónico se enviaran sus resultados por correo postal.
NOTICE OF PRIVACY PRACTICES FOR THE PROTECTION OF PROTECTED HEALTH INFORMATION THAT IDENTIFIES THE INDIVIDUAL
This notice describes how your protected health Information might be used and disclosed and how You can obtain access to the same. Please, review it carefully.
OUR LEGAL RESPONSIBILITY Wellness Alliance is committed to safeguard your Protected Health Information. We are required by Law to maintain the privacy and confidentiality of your protected health information (PHI) and to provide you with this notice of our legal duties and privacy practices with respect to protected health information.
This notice will be effective on December 1, 2008, and will remain effective until we revise it. WELLNESS ALLIANCE will abide by the terms the notice currently in effect.
Wellness Alliance reserves the right to change our privacy practices and the terms of this notice. Before we make a significant change in our privacy practices, we will change this notice and send an updated notice to our active subscribers.
Protected Health Information is information that can identify you (name, last name, social security number); including demographic information (like address, zip code), obtained from you through a request or other document in order to obtain a service, created and received by a health care provider, a medical plan, intermediaries who submit claims for medical services, business associates, and that is related to (1) your health and physical or mental condition, past, present, or future; (2) the provision of medical care to you, or (3) past, present, or future payments for the provision of such medical care. In this Notice, this information will be called protected health information. This Notice of Privacy Practices has been written and amended so that it will comply with HIPAA Privacy Regulations. Any term not defined in this Notice will have the same meaning that it has in the HIPAA Privacy Regulation.
Main Uses and Disclosures of Protected Health Information In order to perform our duties as insurance or benefit administrator, we may use or disclose information for medical treatment, payment of medical services, and health care operations; for example:
Treatment. For the provision, coordination, or supervision of your medical care, and other related services. For example, the plan may disclose medical information to your health care provider for treatment, if so requested.
Payment .To collect or provide payment for medical care, including collections and claims handling. For example, the plan may use or disclose protected health information in order to pay claims for health services rendered, or to provide eligibility information to your health care provider when you receive treatment.
Health Care Operations. For legal purposes and audit processes, including fraud and abuse detention and compliance, as well as the planning and development of businesses and administrative activities and management of businesses. We may use or disclose medical information to another entity related to you and that is also subject to the federal or local rules.
Gathered Information Wellness Alliance has the commitment to limit the information that we gathered to the strictly necessary for the administration of your insurance coverage or benefit. Within our functions of administration, we gathered personal information that you provide in application forms and other documents, transactions with us or with our affiliated companies, credit agencies, and information of health care providers, for example post service claims.
Covered Entities To perform our duties as a health care service provider, Wellness Alliance may use or disclose protected health information.
Business Associates We contract with persons and organizations (business associates) so they can perform certain functions in our name, or to provide certain types of services. In
order to perform these functions or provide these services, business associates may receive, create, maintain, use, or disclose protected health information, but only after they agree in writing to properly safeguard such information. Among the examples of business associates are institutions that offer claims processing, certain accounting activities (CPA), and technical support for medically oriented computer software.
Other Covered Entities We may use or disclose your protected health information in order to assist health care providers with the treatment they provide to you, or with payment activities concerning you. For example, we may disclose or share your protected health information in order to coordinate benefits. We may disclose your protected health information to a health care professional if he or she provides you with treatment.
Other Possible Uses and/or Disclosures of Your Protected Health Information Required by Law. We may use or disclose your protected health information whenever Federal, State, or Local Laws require its use or disclosure. In this Notice, the phrase “as required by Law” is defined the same as it is defined in HIPAA Privacy Standards.
Public Health Activities. We may use or disclose your protected health information for public health activities, including the statistical report on illnesses and vital information, among others.
Health Oversight Activities. We may use or disclose your protected health information to those government agencies that regulate health care related activities.
Food and Drug Administration (FDA). We may use or disclose your protected health information to the FDA in order to prevent to the health or national security in relation to adverse events related to food, supplements, products and product defects, among others.
Abuse Or Neglect. We may use or disclose your protected health information to a government official authorized to receive reports of abuse or neglect against minors or adults or domestic violence situations.
Legal Proceedings. We may use or disclose your protected health information during the course of any judicial or administrative proceedings: (i) in response to an order of a court or administrative tribunal (provided that the covered entity discloses only the protected health information expressly authorized by such order); or (ii) in response to a subpoena, discovery request, or other lawful process.
Law Enforcement Officials. We may use or disclose your protected health information to law enforcement officials. We may use or disclose your protected health information for research purposes. In addition to: Correctional institutions in the case of inmates; as authorized by laws relating to workers’ compensation (Corporacion del Fondo del Seguro del Estado); disaster relief efforts, so that your family may be provided with information about your health condition, and your location.
Other persons participating in your health care. Unless request a restriction (in accordance with the procedure described later in this Notice of Privacy Practices, under “Right to request a restriction”) we may disclose limited protected health information to a friend or family member who is involved with your care, or who are responsible for payment of medical services. If you are not in person, if you are disabled, or it is an emergency, we will use our professional judgment in the disclosure of information that we understand will be in your better interest.
Disclosures to an Authorized Representative. We will disclose your protected health information to a person designated by you as your authorized representative, and who qualifies for this designation in accordance with applicable laws of the Commonwealth of Puerto Rico. However, before we disclose protected health information to your authorized representative, you must provide us with a written document designating this person as such, along with any other support documents (like a power of attorney). Even when you designate an authorized representative, HIPAA Privacy Regulations allow us not to treat this person as your authorized representative if, in our professional judgment, conclude that: (i) you have been or may be subject to domestic violence, abuse, or neglect by such person; (ii) treating such person as your authorized representative could endanger you, or (iii) we, in the exercise of professional judgment, decide that it is not in your best interest to treat this person as your authorized representative. With your authorization: You may authorize us in writing, to use or disclose your protected health information to other persons, for any other purpose. The authorization must be signed and dated by you, it must indicate the person or entity authorized to receive the information, a short description of the information been disclosed, and expiration date for the authorization, which will not exceed two years from the date on which the document is signed. You have the right to revoke the authorization in writing, and the revocation will be in effect for future uses and disclosures of your protected health information. Nevertheless, your revocation will not apply to information that we have already used or disclosed. Unless you submit a written authorization, we may not use or disclose your protected health information for any other reason not described in this Notice.
RIGHT TO PRIVACY
You have the following rights regarding your protected health information. Right to Request a Restriction You have the right to request a restriction to the protected health information that we maintain at Wellness Alliance, and that we use or disclose for treatment, payment, or health care operations. Nevertheless, we are not required by Law to agree to any restriction that you request. If we agree to a restriction, we will comply with the same, unless the information is needed in order to provide you with emergency treatment. You may request a restriction by completing a request form, available at our service centers and through our Internet site. This form must be signed and approved by an authorized official. Right to Confidential Communications You may request that we communicate with you concerning your protected health information using an alternate method or physical location. For example, you may request that we contact you only at your work address, or use only your work phone number. You may request confidential communications by completing a request form, available at our service centers and through our Internet site. Right to Access You have the right to inspect and copy your personal, financial, insurance, or health information, within the limits and exceptions provided by law. In order to access your information, you must submit a written request to the Wellness Alliance’s Security and Privacy Department. You may obtain the request form at our service centers or through our Internet site. The first report that you request will be free. We reserve the right to charge a fee for subsequent copies. We may deny access to inspect or copy your protected health information under certain limited circumstances. If we deny you access to your information, you
may request a review of our denial. In order to request a review, you must contact our Office at the address on this Notice of Privacy Practices. An authorized official will review your request, and denial. Right to Amend If you believe that your protected health information, and that we keep in our files and/or systems, is incomplete or incorrect, you may request that we amend it. You may request to amend your protected health information by completing a request form, available at our service centers or through our Internet site. Your request must include an explanation or evidence to justify an amendment. Your request may be denied. If your request is denied, we will provide you with a written explanation for this denial. Right to an Accounting of Disclosures You have the right to request an accounting of certain disclosures of your protected health information made by MCS, for events not related to medical treatment, payment for medical services, health care operations, or in compliance with your authorization. You may request an accounting of disclosures by completing the request form available at our service centers or through our Internet site. Right to a Printed Copy of this Notice You have the right to obtain a paper copy of this Notice of Privacy Practices at your request, even after agreeing to receive a copy of the same in electronic form.
COMPLAINTS
If you understand that we have incurred in any violation of your privacy rights, or if you disagree with our decisions with regards to access to your protected health information, you have the right to submit a complaint to the address at the end of this Notice. Likewise, you may file a complaint with the Secretary of Health and Human Services (DHHS), at the following address: Region II, Office for Civil Rights, US Department of Health and Human Services (DHHS) Jacob Javits Bldg., 26 Federal Plaza, Suite 3312, New York, 10278; telephone: 1-866-627-7748, or the Internet address: www.hhs.gov/ocr/hipaa. Your complaint should include: (1) the name of the covered entity you are filing a complaint against; (2) brief description of the alleged violation, and (3) file the complaint within 180 days of when the complainant knew of should have known that the act or omission complained of occurred. At Wellness Alliance, we believe in the privacy of our clients protected health information. We will not penalize nor retaliate against you for filing a complaint with the Department of Health and Human Services, or with Wellness Alliance.
CONTACT INFORMATION FOR WELLNESS ALLIANCE
You may request additional information about this Notice of Privacy Practices, or file a complaint with Wellness Alliance at the following address:
WELLNESS ALLIANCE Attention: Privacy Officer
Millennium Park Plaza • 15 2nd Street • Suite 540 Guaynabo, PR 00968
787-708-6777
www.wellnessalliancepr.com www.prevencionpr.com
EFFECTIVE DAY This Notice of Privacy Practices is effective on December 1, 2008.