This service will also introduce you to the LifeLine Questionaire and Information Guide that can explain some
of the unique opportunities that exist for you as a visitor of our CHIPSA healthcare environment.
CHIPSA - Centro Hospitalario Internacional Pacifico, SA is the Mexico Center for Integrative Medicine practicing alternative and complementary medical care. Offering a modern, 6 story hospital housing 70 beds with accompany four-bed intensive-care unit, a full-service surgical ER staff and suite, birthing facilities, state-of-the art anesthesiology, immersion hyperthermia technology, alternative medical research laboratory, x-ray, ultrasound and a 24-hour emergency room. CHIPSA is a community hospital serving the local population’s primary care needs, including birthing and emergencies. CHIPSA provides medical care for several regional corporations. The Gerson Plus Program reserves beds for patients arriving from all over the world, seeking treatment of degenerative diseases with the many integrated therapeutic offerings. CHIPSA hospital is a fully accredited, intensive-care, registered facility.
The CHIPSA Gerson Hospital is the founding medical institution of the Gerson+Therapy developed by Max B. Gerson, MD, founder of Immunonutrition, who is known for his many contributions in chronic and degenerative infectious diseases, as well as the treatment for cancer. CHIPSA is devoted to integrative medicine and is the most experienced hospital practicing complementary and immunonutrition and detoxification therapy on the Pacific Rim.
CHIPSA Hospital, #670, Colonia Jardines del Sol, Playas Tijuana, Mexico C.P. 22700
This site or parts thereof may be linked to for reference only and may not be duplicated in any manner without permission with CHIPSA and the Executive Director of CHIPSA.
C.H.I.P.S.A. All rights reserved. / Marca Registrada: #512642, #512643, #512646 / copyright 2005
STEP FOUR
Personal Medical History is a disclosure of your personal medical history, current medications, physician treatment concerns and the protocols upon which you wish to focus expectations.
PERSONAL MEDICAL HISTORY
Name:_________________________________________________________________________
What is your current stress level? (1=low / 5=high) __1 __2 __3 __4 __5
Current Health Status
High Blood Pressure __Yes __No Diagnosis Date _____________ Treatment _____________
Heart Disease __Yes __No Diagnosis Date _____________ Treatment _____________
Stroke/Thrombosis __Yes __No Diagnosis Date _____________ Treatment _____________
Diabetes __Yes __No Diagnosis Date _____________ Treatment _____________
Arthritis __Yes __No Diagnosis Date _____________ Treatment _____________
Liver Disease __Yes __No Diagnosis Date _____________ Treatment _____________
Gall Bladder Disease __Yes __No Diagnosis Date _____________ Treatment _____________
Kidney Disease __Yes __No Diagnosis Date _____________ Treatment _____________
Seizure Disorder __Yes __No Diagnosis Date _____________ Treatment _____________
Lung Disease __Yes __No Diagnosis Date _____________ Treatment _____________
Asthma __Yes __No Diagnosis Date _____________ Treatment _____________
Emphysema __Yes __No Diagnosis Date _____________ Treatment _____________
Other: _________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Cancer __Yes __No Diagnosis Date ______________________ Treatment __________________
Type______________________________ Stage_______________________________________
Type______________________________ Stage_______________________________________
Have you had any chemotherapy? __Yes __No
If yes, how many treatments? _______________________________________________________
For how long did you receive radiation? ______________________________________________
Was the radiation ___successful ___not successful ___no effect realized.
Treatment history or concerns: ______________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Please list all surgeries (i.e., include cosmetic, implants, biopsies):
Name of surgical procedure and year of operation:
1. _______________________________________________________ date_________________
2. _______________________________________________________ date_________________
3. _______________________________________________________ date_________________
4. _______________________________________________________ date_________________
5. _______________________________________________________ date_________________
6. _______________________________________________________ date_________________
7. _______________________________________________________ date_________________
8. _______________________________________________________ date_________________
9. _______________________________________________________ date_________________
Any tattoos or piercings? __Yes __No. If yes, where?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
CURRENT MEDICATIONS: Please list, including dosage and when you started taking medication:
1. _______________________________________________________ date_________________
2. _______________________________________________________ date_________________
3. _______________________________________________________ date_________________
4. _______________________________________________________ date_________________
5. _______________________________________________________ date_________________
6. _______________________________________________________ date_________________
7. _______________________________________________________ date_________________
8. _______________________________________________________ date_________________
9. _______________________________________________________ date_________________
Note: Please do not discontinue any medications until advised by your private medical doctor.
Recreational drugs? __Yes __No If yes, how much-how long?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
“Street drugs” __Yes __No If yes, which ones? _______________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
DEGENERATIVE INFECTIOUS DISEASE: (optional)
To your knowledge, are you HIV positive? __Yes __No
To your knowledge, do you have AIDS? __Yes __No
Have you had blood transfusions? __Yes __No If yes, when?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Blood type, if known: _______________
Have you contracted any of the following disease/infections?
Sexually Transmitted Diseases
Syphilis __Yes __No If yes, when? _________________________________________________
Gonorrhea __Yes __No If yes, when? _______________________________________________
Genital Herpes __Yes __No If yes, when? ___________________________________________
Genital Warts __Yes __No If yes, when? _____________________________________________
Chlamydia trachomatis __Yes __No If yes, when? _____________________________________
Miscellaneous:
Candida albicans __Yes __No
Trichomonas vaginalis __Yes __No
Other, please list: _______________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Bacterial - Viral Infections:
Herpes simplex __Yes __No If yes, when? _______________
Tuberculosis __Yes __No If yes, when? _______________
Malaria __Yes __No If yes, when? _______________
Meningitis: Viral __Yes __No If yes, when? _______________
Meningitis: Bacterial __Yes __No If yes, when? _______________
Encephalitis __Yes __No If yes, when? _______________
Streptococcal __Yes __No If yes, when? _______________
Staphylococcal __Yes __No If yes, when? _______________
Septicemia __Yes __No If yes, when? _______________
Brucellosis __Yes __No If yes, when? _______________
Candidiasis __Yes __No If yes, when? _______________
Listeria __Yes __No If yes, when? _______________
Salmonella __Yes __No If yes, when? _______________
Camphylobacter __Yes __No If yes, when? _______________
Heliobacter __Yes __No If yes, when? _______________
Dysentry __Yes __No If yes, when? _______________
Hepatitis: A __Yes __No If yes, when infected? _______________
Hepatitis: B __Yes __No If yes, when infected? _______________
Hepatitis: C __Yes __No If yes, when infected? _______________
Epstein Barr __Yes __No If yes, when infected? _______________
Cytomegalovirus __Yes __No If yes, when infected? _______________
Treatment history or concerns: ______________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Females Only:
Age at onset of menstruation? _______________
How many pregnancies?____________ Miscarriage ______________ Abortions _____________
Number of children?_____________ Alive _____________ Deceased _____________
Cesarean section? _______________
Age at onset of menopause? _______________
Have you taken oral contraceptive pills? __Yes __No
If yes, for how long? ______________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Hormone Replacement Therapy (HRT)? __Yes __No
If yes, for how long? ______________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Have you experienced any other following? (please check)
__absence of periods
__cervical dysplasia
__endometriosis
__hemorrhage
__infection in reproductive organs
__infertility
__yeast infections
__ovarian cysts
__premature birth
__still birth
__diabetes during pregnancy
__pelvic inflammatory disease
__tubal pregnancy
__toxemia
__irregular cycle
__placenta previa
__uterine fibroids
Other medical information of interest: ________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
If yes, for how long? ______________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Note, that while CHIPSA frequently updates content, medical information changes rapidly. Therefore, some information may be out-of-date during contact or stay with CHIPSA.
Please speak with a physician if you suspect you are too ill to answer.
© CHIPSA 2005
© CHIPSA 2009 All rights reserved. Marca Registrada: #512642, #512643, #512646