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.

LifeLine Information Guide: Patient Summary

The LifeLine Questionaire Information Guide explains some of the unique opportunities that exist for you as a potential recipient of our CHIPSA healthcare environment. As you complete the LifeLine Questionaire just know one of our Patient Service specialists is never more than a phone call or click away. Please download or view as similar as below: Step Three.
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 THREE

Patient Information Summary helps you and us begin a pre-authorized patient summary review of your health history. This step asks you to identify decision-lifestyle influencers (such as; dental, allergies, diet, herbal supplements, etc.) and points to any additional family information you may have encountered during your search for the best medical care.

EXPOSURE: Have you been exposed to any of the following?

Agricultural chemicals? __Yes __No If yes, please list below:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Industrial/Workplace chemicals? __Yes __No If yes, list below:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Cigarette smoking? __Yes __No If yes, how much?____________________________________
If yes, how long? ________________________________________________________________

When last cigarette smoked? ______________________________________________________
Second hand smoke? __Yes __No If yes, how much?___________________________________
Alcohol use? __Yes __No How much? ______________________________________________

Past Occupations:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________


DENTAL HISTORY:

Have silver-mercury fillings? __Yes __No If yes, how many? _____
Do you have root canals? __Yes __No If yes, how many? _____
Have you been tested for having metal toxicity? __Yes __No
If yes, please describe:____________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________


FOOD ISSUES / SENSITIVITIES:

Do you have any food allergies? __Yes __No If yes, list below:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Do any foods give you gas, pain, or bloating? __Yes __No
If yes, please list _________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Any tattoos or piercings? __Yes __No. If yes, when and where?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Please describe your diet (e.g., organic vegetable, fruit, juicing, restaurants 3 times per week, etc.)
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Stomach Disorders or General Digestion Problems

Acid Indigestion __No __Yes, in the past / __Yes, currently
Acid Reflux __No __Yes, in the past / __Yes, currently
Bloating/Flatulence __No __Yes, in the past / __Yes, currently
Colitis __No __Yes, in the past / __Yes, currently
Constipation __No __Yes, in the past / __Yes, currently
Diarrhea __No __Yes, in the past / __Yes, currently
Diverticulitis __No __Yes, in the past / __Yes, currently
Hiatal Hernia __No __Yes, in the past / __Yes, currently
Irritable Bowel Syndrome __No __Yes, in the past / __Yes, currently
Ulcers __No __Yes, in the past / __Yes, currently

Please list dosage of supplements, vitamins, or herbs you consume.
 1. ________________________________ When started:_______________________________
2. ________________________________ When started:_______________________________
3. ________________________________ When started:_______________________________
4. ________________________________ When started:_______________________________
5. ________________________________ When started:_______________________________
6. ________________________________ When started:_______________________________
7. ________________________________ When started:_______________________________
8. ________________________________ When started:_______________________________
9. ________________________________ When started:_______________________________


FAMILY HISTORY:

Mother: __Alive __Deceased
Father: __Alive __Deceased
Sisters: Number Alive ___ Number Deceased ___
Brothers: Number Alive ___ Number Deceased ___

Please insert the name of the family member wherever it applies below.
Include parents, brothers-sisters, aunts-uncles, grandparents and children.

High Blood Pressure __Yes __No _________________________________________________
Heart Disease __Yes __No ______________________________________________________
Stroke-Thrombosis __Yes __No __________________________________________________
Diabetes __Yes __No ___________________________________________________________
Arthritis __Yes __No ___________________________________________________________
Liver/Gall Bladder Disease __Yes __No ____________________________________________
Lung Disease __Yes __No ______________________________________________________
Asthma __Yes __No ___________________________________________________________
Emphysema __Yes __No _______________________________________________________
Kidney Disease __Yes __No _____________________________________________________
Seizure Disorder __Yes __No ____________________________________________________
Auto-immune disease __Yes __No _______________________________________________
Rheumatoid Arthritis __Yes __No __________________________________________________
SLE (Lupus) __Yes __No ________________________________________________________
Celiac __Yes __No _____________________________________________________________
Chrons __Yes __No ____________________________________________________________
Hyperthyroidism __Yes __No _____________________________________________________
Hypothyroidism __Yes __No _____________________________________________________
Multiple Sclerosis __Yes __No ___________________________________________________
Mental Disease/Depression __Yes __No ____________________________________________

Cancer:
Type__________________________ Relative__________________________________________
Type__________________________ Relative__________________________________________
Type__________________________ Relative__________________________________________
Type__________________________ Relative__________________________________________
Type__________________________ Relative__________________________________________
Type__________________________ Relative__________________________________________

Other:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________


SOCIAL HISTORY:

Do you have family/friends for a support system? __Yes __No
Do you practice a spiritual, religion, belief system or faith? __Yes __No
May we understand? _____________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Have you recently experienced significant losses? __Yes __No
(i.e., family / friend / job / pet / divorce / financial / mobility )
If yes, please explain: _____________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

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
LifeLine Guide
© CHIPSA 2009 All rights reserved. Marca Registrada: #512642, #512643, #512646
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