Notes
My History of Medical Care
in Mexico
____________________________________
Name
From _____________________
To ________________________
Many Mexican doctors do not keep your medical records. And
of those who do they are in Spanish. Use this booklet to keep
track of your basic health status and health care received in
Mexico. This will provide you with a valuable record of your
treatments and progress, and may be important if you return to
your home country for continued care of a condition initially
treated in Mexico.
Provided by San Miguel Medical Resource Directory
My History of Medical Care in Mexico
Appointments and Treatments
Briefly describe nature of visit and treatment given or
prescribed
Date
Doctor
Reason for visit
Treatment
Other comments
This is designed to be printed on two sides
Follow your printer’s instructions for
double-sided printing
This Booklet is not copyrighted.
Please feel free to share this with your
friends and family.
Make copies for your Care Groups in case
of emergency.
Date
Reason for visit
Treatment
Other comments
Doctor
Date
Reason for visit
Treatment
Other comments
Doctor
Date
Reason for visit
Treatment
Other comments
Doctor
Date
Reason for visit
Treatment
Other comments
Doctor
9
My History of Medical Care in Mexico
Appointments and Treatments
Briefly describe nature of visit and treatment given or
prescribed
Date
Doctor
Reason for visit
Treatment
Other comments
Date
Reason for visit
Treatment
Other comments
Doctor
My History of Medical Care in Mexico
Patient Information
Patient’s Name:
Address
City
Colonia
State
ZIP
Home Phone
Country
Cell Phone
Country
Other Phone(s)
E-mail
Date
Reason for visit
Treatment
Other comments
Doctor
Date
Reason for visit
Treatment
Other comments
Doctor
Date
Reason for visit
Treatment
Other comments
Doctor
Languages Spoken:
Person(s) to contact in case of emergency:
Durable Power of Attorney
Primary Advocate:
Telephone
Secondary Advocate:
Telephone
Insurance Carrier:
Agent:
Telephone
8
1
Country
My History of Medical Care in Mexico
Family History
Indicate grandparent, parent sibling, child
Hypertension
Appointments and Treatments
Briefly describe nature of visit and treatment given or
prescribed
Date
Doctor
Reason for visit
Treatment
Other comments
Diabetes
Cancer (Specify)
Heart Disease
Date
Reason for visit
Treatment
Other comments
Doctor
Date
Reason for visit
Treatment
Other comments
Doctor
Date
Reason for visit
Treatment
Other comments
Doctor
Date
Reason for visit
Treatment
Other comments
Doctor
Obesity
Neurological disorder (Specify)
Other Conditions (e.g., Rheumatoid Arthritis, Parkinson’s
Multiple Sclerosis, Mental Health Issues)
Personal History
 Smoking: Start
Cigarettes/Day
Stop
 Alcohol: Start
Quantity/Day
Stop
 Drug Use: Type:
 Exercise: Type:
How often
Blood type____________Have you had blood transfusions?
(Date(s) and reason:
2
7
My History of Medical Care in Mexico
Personal History, continued
Do you have/have you had:
Indicate date of onset/diagnosis
 High Cholesterol
 Parkinson’s
 Diabetes
 Asthma
 Urinary Tract Infections
 Depression
 Gastrointestinal
 Glaucoma
 Hypertension
 Cardiovascular
 Heart Disease
 Prostate
 Cancer (type)
 Blood Disorders (type)
 Neurological Disorders (type)
 Allergies (type)
Other:
Illness
Treatment
Illness
Treatment
Illness
Treatment
Illness
Treatment
Illness
Treatment
My History of Medical Care in Mexico
Medication History
Include over-the-counter, supplements and prescriptions
Name of Medication
Dates(s) Taken Allergic?
Major Illnesses
Date
Duration
Date
Duration
Date
Duration
Date
Duration
Date
Duration
Surgery
Surgery
Date
Surgery
Surgery
Date
Date
6
3
My History of Medical Care in Mexico
Hospitalizations
Briefly describe all hospitalizations and emergency room visits,
reasons for hospitalization and treatments given
Date
Hospital
Reason for hospitalization
My History of Medical Care in Mexico
Treating Physicians and Health Care Professionals
Primary Doctor(s) in Mexico:
Telephone
Other Doctor
Telephone
Treatment
Treating Physician
Comments
Specialty
Date
Hospital
Reason for hospitalization
Other Doctor
Telephone
Specialty
Treatment
Other Doctor
Treating Physician
Comments
Telephone
Specialty
“Alternative Care” Professionals (Acupuncture, Chiropractic,
Naturopath, Homeopath, etc)
Name
Telephone
Date
Hospital
Reason for hospitalization
Practice
Treatment
Name
Treating Physician
Comments
Practice
Telephone
Name
Telephone
Practice
4
5