Historia clinica

Introduction Indicaciones Terms of Service Gender Personal History Cardiovascular Problems Diseases of Circulatory System Autoinmune or Infectious Diseases Pulmonary & Respiratory Diseases Urological Diseases Diseases of Liver, Gallbladder and Pancreas Gastrointestinal Problems Skin Diseases Muscular & skeletal diseases Cancer Endocrine Diseases Neurological Diseases Psychiatric Conditions Blood Related Conditions Medication and Supplement Allergies Interview with the doctor

Introduction

Welcome to Kaloni!

Please provide the following information to access your medical history:

Enter your email address

Enter your date of birth

Please fill in all the 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. Utilice los botones inferiores de la pantalla, “Atrás” para regresar al bloque anterior, “Siguiente” para cambiar de bloque y “Guardar” para conservar su información de cada bloque.
5. Se sugiere utilice el botón de “guardar” al completar cada bloque, esto le permitirá regresar a ella en donde se quedó, por si no lograra completar del todo su historial clínico.
6. Si no logró completar todos los bloques de su historial clínico, podrá ingresar de nuevo a él mediante el link que previamente se le compartió, registrando su correo electrónico y fecha de nacimiento.

Para nosotros es muy importante ayudarte a mejorar tu calidad de vida.

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 fill in all the information.

Paciente

Select your assigned gender at birth

Female

Male

Please fill in all the information.

Paciente

¿Cuántos años tiene usted?

Please fill in all the information.

Personal History

Personal History Seleccione una respuesta en cada fila.
Recuerde dar click en guardar para salvar su progreso.

Height (cm)

Weight (kg)

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 have any difficulty walking?

Yes

Do you need wheelchair?

Yes

Do you need crutches or a cane?

Yes

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

Yes

On what date?

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

Yes

Por favor, complete toda la información

Cardiovascular Problems

Cardiovascular Problems Seleccione una respuesta en cada fila.
Recuerde dar click en guardar para salvar su progreso.

Have you had a heart attack?

Yes

Do you remember when your last heart attack was?

Yes

On what date?

How many times?

Have you undergone rehabilitation after your heart attack?

Yes

Describe the improvements after your rehabilitation

Do you remember the date of your last echocardiogram?

Yes

On what date?

Do you know your ejection fraction measurement?

Do you have chest pain?

Yes

Do you have shortness of breath?

Yes

When you are at rest or when you workout?

Resting

Working out

Do you have pressure, heaviness, tightness or pain in your chest?

Yes

Have you had Angioplasty?

Yes

Do you remember the date of your angioplasty?

Yes

On what date?

Have you undergone By-pass Surgery?

Yes

Do you remember the date?

Yes

On what date?

Do you have high blood pressure?

Yes

Do you remember since when do you have high blood pressure?

Yes

On what date?

Please indicate your treatment:

Do you have low blood pressure?

Yes

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

Yes

Do you have any significant heart problems that you would like to share with us?

Yes

Which one?

Have you been diagnosed with a terminal heart condition or are you on the waiting list for a transplant?

Yes

Por favor, complete toda la información

Diseases of Circulatory System

Diseases of Circulatory System Seleccione una respuesta en cada fila.
Recuerde dar click en guardar para salvar su progreso.

Do you have poor arterial circulation?

Yes

Have you ever been diagnosed with carotid artery disease?

Yes

Have you had a stroke?

Yes

Do you remember the date?

Yes

¿En qué fecha?

If you have consequences, describe them.

Do you have any of these symptoms?:

Swollen ankles

Yes

Poor venous circulation

Yes

Varicose veins in lower limbs

Yes

Have you ever suffered from thrombosis in the arteries or veins?

Yes

Have you ever suffered from a lung embolism?

Yes

Do you currently have sequels?

Yes

Do you have any of these symptoms?:

Numbness of arms and/or legs

Yes

Ulcers or open wounds on any part of the skin

Yes

Tell us the anatomical site (Part or area of the body)

Have you ever been diagnosed with arteritis?

Yes

What type?

Have you been diagnosed with any terminal circulatory condition that requires limb amputation?

Yes

Por favor, complete toda la información

Have you had any of these autoimmune or infectious diseases?

Have you had any of these autoimmune or infectious diseases? Seleccione una respuesta en cada fila.
Recuerde dar click en guardar para salvar su progreso.

Hashimoto's disease

Yes

Graves' disease

Yes

Fibromyalgia

Yes

Chronic fatigue

Yes

Epstein Barr infection

Yes

HIV

Yes

What treatment do you use?

Have you had HIV tests?

Yes

Do you remember the date of your last test?

Yes

Date of your last test

Any other viral or bacterial illness?

Yes

Which one?

Lyme's desease

Yes

Systemic lupus erythematosus

Yes

Rheumatoid arthritis

Yes

Sjogren's syndrome

Yes

Scleroderma

Yes

Dermatomyositis

Yes

Vasculitis

Yes

Severe myasthenia

Yes

Addison's disease

Yes

Inflammatory Bowel Disease (Crohn's, ulcerative colitis)

Yes

Psoriasis

Yes

Do you have any unknown immune conditions?

Yes

Which one?

Do you have long term post-COVID symptoms?

Sí

Por favor, complete toda la información

Pulmonary & Respiratory Diseases

Pulmonary & Respiratory Diseases Seleccione una respuesta en cada fila.
Recuerde dar click en guardar para salvar su progreso.

Asthma

Yes

Chronic Bronchitis

Yes

Chronic Obstructive Lung Disease

Yes

Pulmonary Emphysema

Yes

Sarcoidosis

Yes

Pulmonary fibrosis

Yes

Tuberculosis

Yes

Chronic sinusitis

Yes

Allergic rhinitis

Yes

Chronic Colds

Yes

Nasal bleeding

Yes

Do you have any other infectious respiratory problems?

Yes

Which one?

Por favor, complete toda la información

Urological Diseases

Urological Diseases Seleccione una respuesta en cada fila.
Recuerde dar click en guardar para salvar su progreso.

Acute Kidney Failure

Yes

Chronic Kidney Disease

Yes

Diabetic nephropathy

Yes

Glomerulonephritis

Yes

Polycystic kidney disease

Yes

Nephrotic syndrome

Yes

Have you been on Dialysis?

Yes

Are you on dialysis?

Yes

Do you have any kidney vascular disease?

Yes

Which one?

Do you have a terminal kidney disease that requires a transplant?

Yes

Do you have kidney stones or anywhere else in the urinary system?

Yes

Do you have any other urethral conditions?

Yes

Which one?

Do you have any other bladder conditions?

Yes

Which one?

Do you have any prostate problems?

Yes

Which one?

Do you have to go to urinate frequently?

Yes

Do you have urinary incontinence?

Yes

do you have vaginal prolapse?

Yes

Does it cause urinary or fecal incontinence?

Urinary

Fecal

do you have a history of vaginal pain or any pain related to sexual interaction?

Yes

have you suffered any changes in erectile function?

Yes

If you have taken medications to improve erectile function, have they solved the problem?

Yes

have you suffered any changes in ejaculation patterns?

Yes

If you have taken medications to improve ejaculation patterns, have they solved the problem?

Yes

Por favor, complete toda la información

Diseases of Liver, Gallbladder and Pancreas

Diseases of Liver, Gallbladder and Pancreas Seleccione una respuesta en cada fila.
Recuerde dar click en guardar para salvar su progreso.

Do you have a fatty liver?

Yes

Do you have Cirrhosis?

Yes

Do you have viral hepatitis?

Yes

Wich one?

Do you have any liver problems?

Yes

Which one?

Do you have a gallbladder problems?

Yes

Which one?

Do you have gallbladder stones?

Yes

Do you have pancreatitis related to gallstones?

Yes

Do you have any bile duct problems?

Yes

Which one?

Do you have any alcohol-related pancreas problems?

Yes

Which one?

Do you have chronic pancreatitis?

Yes

Have you had chronic pancreatitis?

Yes

Do you have any other problems with your pancreas?

Yes

Which one?

Do you suffer or have you suffered Jaundice?

Yes

Por favor, complete toda la información

Gastrointestinal Problems

Gastrointestinal Problems Seleccione una respuesta en cada fila.
Recuerde dar click en guardar para salvar su progreso.

Have you experienced any changes in appetite?

Yes

Have you had any medical history of eating disorders?

Yes

Accelerated weight gain?

Yes

Accelerated weight loss?

Yes

Have you had any of these changes in your bowel habits?:

Recurrent diarrhea

Yes

Abdominal distension

Yes

Flatulence

Yes

Loss of appetite

Yes

Do you have any history of Heartburn?

Yes

Do you suffer from cough after eating?

Yes

Do you have Gastric Reflux?

Yes

Do you have a history of any of these conditions?:

ESOFAGITIS

Yes

ULCERA GASTRICA

Yes

ULCERA DUODENAL

Yes

COLONOSCOPIA

Yes

Do you remember the date?

Yes

¿En qué fecha?

GASTROSCOPY

Yes

Do you remember the date?

Yes

¿En qué fecha?

Por favor, complete toda la información

Skin Diseases

Skin Diseases Seleccione una respuesta en cada fila.
Recuerde dar click en guardar para salvar su progreso.

Do you have acne vulgaris?

Yes

Do you have Atopic dermatitis or any type?

Yes

Do you have hives (urticaria) of any type?

Yes

Do you have contact dermatitis?

Yes

Have you had any sudden changes of the condition of your skin (dry skin, excesive sweating, oily skin)?

Do you have Rosacea?

Yes

Do you have a history of any fungal, bacterial or viral skin infections?

Yes

Do you have Herpes Zoster?

Yes

Do you have herpes labialis?

Yes

Do you have Genital Herpes?

Yes

Do you have wound healing problems? (example: keloid scarring or other problems associated with wound healing)

Yes

Por favor, complete toda la información

Muscular & skeletal diseases

Muscular & skeletal diseases Seleccione una respuesta en cada fila.
Recuerde dar click en guardar para salvar su progreso.

Do you have any history of skeletal muscle disease?

Yes

Which one?

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

Yes

Describe it

Have you had any changes in your range of motion related to your muscles or joints?

Yes

Describe it

Have you suffered a bone fracture?

Yes

Have you suffered from tendonitis (example: tennis elbow, golfer's elbow, Achilles tendon, other)?

Yes

Do you have any history of plantar fasciitis?

Yes

Do you have any history of ligament or cartilage disease (example: menisci, cruciate ligaments, collateral ligaments, others)?

Yes

Do you have any history of arthritis of any type (example: osteoarthritis or rheumatoid)?

Yes

Do you have any pain in any joint or muscle even when you are not moving?

Yes

Por favor, complete toda la información

Cancer

Cancer Seleccione una respuesta en cada fila.
Recuerde dar click en guardar para salvar su progreso.

Have you ever had cancer?

Yes

Specify what type of cancer

Please indicate how you were diagnosed:

What stage was your cancer at when you were diagnosed?

Do you remember the date of your diagnosis?

Yes

Date of your relapse

If you were cured of cancer, indicate how long ago it was

Specify the treatment received:

Indicate if you have had recurrence:

Yes

Do you remember the date of your recurrence?

Yes

Date of your relapse

Do you currently have cancer?

Yes

Please indicate the current status of your cancer

Do you have family history of cancer?

Yes

What kind of cancer history?

Have you had any genetic testing to find out if you are predisposed for cancer?

Yes

Did the test showed increase risk for cancer?

Yes

Did the test show a probability of any other disease?

Yes

Por favor, complete toda la información

Endocrine Diseases

Endocrine Diseases Seleccione una respuesta en cada fila.
Recuerde dar click en guardar para salvar su progreso.

Have you had any condition related to the pituitary gland?

Yes

Which one?

Do you have any thyroid disease?

Yes

Which one?

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

Yes

Do you have adrenal gland dysfunction?

Yes

Have you had any problems related to Menopause?

Yes

Have you had any problems related to Andropause?

Yes

Do you have cholesterol metabolic disorders?

Yes

Do you suffer from obesity?

Yes

Por favor, complete toda la información

Neurological Diseases

Neurological Diseases Seleccione una respuesta en cada fila.
Recuerde dar click en guardar para salvar su progreso.

Did you have any head trauma?

Yes

Did the head trauma evolve into brain damage?

Do you have any history of spinal cord trauma?

Yes

Have you experienced a decrease in vision?

Yes

Did you ever have concusion?

Yes

Have you had changes in short-term or long-term memory?

Yes

Have you ever been diagnosed with Alzheimer's or any type of dementia?

Yes

Do you have Multiple Sclerosis?

Yes

Do you have Parkinson's disease?

Yes

Have you had frequent fainting episodes?

Yes

Have you experienced sudden changes in:

VISION

Yes

TASTE

Yes

SMELL

Yes

HEARING

Yes

BALANCE

Yes

Have you ever had experienced speach changes or difficulties in speaking?

Yes

Have you experienced episodes of depression that were not present before?

Yes

Do you have muscle loss?

Yes

Have you ever experienced changes in the strength of the upper or lower extremities?

Yes

In extremities:

Upper

Lower

Ambas

In which side?

Right

Left

Ambas

Have you ever experienced changes in the sensation of the upper or lower extremities?

Yes

In extremities:

Upper

Lower

Ambas

In extremities:, In which side?

Right

Left

Ambas

Do you have leg cramps?

Yes

Do you have a tingling sensation in your arms and legs?

Yes

Have you ever been diagnosed with a herniated disc?

Yes

What were the symptoms?

What treatment have you had?

Do you have muscle weakness?

Yes

Do you have a decrease in strength in your hands?

Yes

Have you experienced fainting episodes?

Yes

Do you have difficulty speaking?

Yes

Do you have spasms?

Yes

Have you experienced hyperreflexia?

Yes

Have you experienced hyporeflexia?

Yes

Have you ever experienced memory loss?

Yes

Have you ever had dizziness episodes?

Yes

Por favor, complete toda la información

Psychiatric Conditions

Psychiatric Conditions Seleccione una respuesta en cada fila.
Recuerde dar click en guardar para salvar su progreso.

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?

Sí

Do you currently suffer from any type of psychosis?

Yes

Have you previously suffered from any type of psychosis?

Yes

Do you currently have any psychiatric condition as a complication of taking prescribed medications or recreational drugs?

Yes

Do you currently have any psychiatric condition as a complication of taking prescribed medications or recreational drugs?

Yes

Por favor, complete toda la información

Blood Related Conditions

Blood Related Conditions Seleccione una respuesta en cada fila.
Recuerde dar click en guardar para salvar su progreso.

Do you have coagulation problems?

Yes

Whats is your problem?

Have you had a history of arterial thrombosis?

Yes

Have you had a history of venous thrombosis?

Yes

Have you suffered from any type of anemia?

Yes

Do you have hemophilia or any disorder of blood coagulation?

Yes

Have you experienced excessive or prolonged bleeding after a simple cut?

Yes

Have you ever received transfusion of blood or blood derivative?

Yes

Do you have any problems?

Sí

If so, please describe them.

Por favor, complete toda la información

Medication and Supplement

Medication and Supplement Seleccione una respuesta en cada fila.
Recuerde dar click en guardar para salvar su progreso.

Write down all the medications and/or supplements you are taking, including the dosage if known.

Do you take contraceptives?

Yes

Which ones?

Do you take hormone therapy?

Yes

Please specify which one

Have you ever taken non-steroidal anti-inflammatory drugs (NSAIDs) that do not belong to the steroid family?
*(NSAID) Farmacos antiflamatorios no esteroides

Yes

Which ones?

Do you remember the date?

Yes

When was your last dose?

Have you been or are you currently in a treatment with corticosteroids or steroids?

Yes

Which one?

Have you taken anabolic steroids?

Yes

Which one?

Have you used or are using human growth hormone or taken medication to increse that hormone?

Yes

Which one?

Have you used or are using testosterone or taken medication to increase testosterone?

Sí

Which one?

Have you had a progesterone or testosterone therapy?

Yes

Which one?

Por favor, complete toda la información

Allergies

Allergies Seleccione una respuesta en cada fila.
Recuerde dar click en guardar para salvar su progreso.

Are you allergic to any medications?

Yes

Do you have any other allergies?

Yes

What type of allergy?

Specify your allergy

Por favor, complete toda la información

Interview with the doctor

Thank you for trusting Kaloni!

We have finished the first part of your medical history Shortly, you will be contacted by the specialist doctor who attends to you, to continue with the final part of your medical history. “Interview with the doctor”.

Please fill in all the information.