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Part A Full name: ________________________________ DOB: _______________ Allergies: __________________Emergency contact No.: _____________
Parte A Nombre completo Fecha de nacimiento Alergias Teléfono en caso de emergencia
Annual Health and Medical Record
Registro Médico y de Salud Anual
Part A/Parte A
GENERAL INFORMATION/INFORMACIÓN GENERAL
Name ___________________________________________________ Date of birth __________________________________ Age ___________ Male Female
Nombre Fecha de nacimiento (MM/DD/Year) - (MM/DD/Año) Edad Masculino Femenino
City _________________________________________________________ State _____________ Zip _____________________ Phone No. ______________________________
Ciudad Estado Código postal No. telefónico
Unit leader ___________________________________________________ Council name/No. __________________________________________ Unit No. __________________
Líder de la unidad Nombre y no. del concilio No. de unidad
Social Security No. (optional; may be required by medical facilities for treatment) __________________________________ Religious preference _______________________
No. de Seguro Social (opcional; puede ser solicitado por las instalaciones médicas para brindar tratamiento) Preferencia religiosa
Health/accident insurance company ___________________________________________________________ Policy No. _______________________________________________
Compañía de seguro médico/accidental No. de póliza
ATTACH A PHOTOCOPY OF BOTH SIDES OF INSURANCE CARD. IF YOU DO NOT HAVE MEDICAL INSURANCE, ENTER “NONE” ABOVE.
ANEXAR UNA FOTOCOPIA DE AMBOS LADOS DE LA TARJETA DEL SEGURO. SI USTED NO TIENE SEGURO MÉDICO, ESCRIBA “NINGUNO.”
In case of emergency, notify/En caso de emergencia, notificar a:
Name ________________________________________________________________________________ Relationship ___________________________________________________