Formulario de paciente / Patient Form Nombre y Apellido / Name & SurnameFecha de Nacimento / Date of BirthTelefono / Telephone NumberEmailEnfermedad Cardiaca / Heart ProblemYes/SiNoEnfermedad Respiratoria / Respiratory DiseaseYes/SiNoDiabetes / DiabetesYes/SiNoEnfermedad Osteoarticular / Osteoarticular DiseaseYes/SiNoHipertension / HypertensionYes/SiNoHipertension / HypertensionYes/SiNoDependencia / Dependence LevelYes/SiNoColesterol / CholesterolYes/SiNoCuidado Personal / Personal CareYes/SiNoFumador/a / SmokerYes/SiNoProblems Cronicos del Piel / Skin ProblemsYes/SiNoMala Circulacion / Poor CirculationYes/SiNoAnemia / AnaemiaYes/SiNoProblemas Tiroides / Thyroid ProblemsYes/SiNoMedicacion/s / Medication/sDateOtro Info / Additional InformationPlease type the characters*This helps us prevent spam, thank you.SendThis field should be left blank
