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COLEGIO SEK - PARAGUAY FICHA MÉDICA INTERSEK DEPORTIVO MUNDIAL 2013 MEDICAL REPORT Nombre:________________________________________________________________________ Name Curso/Grado:______________ Fecha:____________ Grade Date of birth Teléfono:____________________ Phone number 1) Presenta alguna enfermedad / Do you haveany of the following: a) Respiratoria / Breathing conditions: ____________________________________________ b) Cardiacas / Heart Conditions: _________________________________________________ c) Otros / Others: _____________________________________________________________ 2) Medicamento que toma y dosis / Types of medicines taken and doses: _______________________________________________________________________________ _______________________________________________________________________________ 3) Presenta Alergias a / Allergies present in: Alimentos / Food :___________________________________________________ Medicamentos / Medicine: ___________________________________________________ Picaduras de insectos / Insect bites: ____________________________________________ Otros / Others : ___________________________________________________ 4) Vacunas recentes / recent vaccinations: __________________________________ ___________________________________________________________________ 5) Cuidados especiales de salud, por recomendación médica / Special health considerations and / or prescription: _______________________________________________________________________________ _______________________________________________________________________________ 6) En caso de emergencia avisar a / In case of an emergency contact:_______________________ Teléfono / phone number:__________________________________________________________ Observaciones generales / general comments: __________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ 7) Seguro médico / Health insurance company: ________________________________________
