Wellness Care Complete

Instrucciones Generales

Su tiempo es valioso por lo que hemos reservado y personalizado su cita. Si por alguna razón no puede asistir a su cita, por favor, avísenos con por lo menos 24 horas de anticipación.

Para que el programa Wellness Care Complete funcione de la manera más eficiente, su cita se programa para la fecha y hora indicada. Su puntualidad es indispensable.

Favor leer las instrucciones y enviar los documentos requeridos antes de su cita por fax (787-708-6779) o vía correo electrónica a info@prevencionpr.com. Si tiene menos de 32 años no tiene que completar el cuestionario Coronary Risk Profile.

Estamos localizados en Metro Office Park, Edificio Millennium Park Plaza # 15, Second Street, Suite 540, Guaynabo PR.

Durante su evaluación se estarán realizando diferentes pruebas que requieren su concentración por lo que le recomendamos que no venga acompañado(a) por niños.

Traiga su tarjeta de identificación de su Plan Médico o la autorización de la empresa para la cual labora, si aplica.

El día del examen debe estar en ayuna desde las 12:00 a.m. de la noche anterior. (No tome alimentos ni bebidas después de las 12:00 de la medianoche)

Traiga sus medicamentos recetados para que los tome cuando se le indique.

A los caballeros mayores de 40 años se le realizará la prueba de PSA sanguíneo y un examen rectal.

Para su seguridad y debido a la exposición de radiación, no se realizará la placa de pecho a las féminas que estén embarazadas o sospechen estarlo, o si están lactando.

Si tiene preguntas o dudas, o necesita información adicional, llámenos al 787-708-6777 ó 787-708-6778.

La alianza de salud para su empresa

Millennium Park Plaza, #15 Second ST, suite 540 Guaynabo, PR 00968 PO Box 9419 San Juan, Puerto Rico, 00908

www.wellnessalliancepr.com

CONSENTIMIENTO / CONSENT

WELLNESS CARE COMPLETE

Yo ______________________________________ autorizo a Wellness Alliance a realizar

las siguientes pruebas como parte de la Evaluación Preventiva Anual. /

I _________________________________________ authorize Wellness Alliance to perform

the following tests as part of the Annual Preventive Evaluation.

Laboratorios/Laboratories

Evaluación de Próstata (hombres mayores de 40 años) con PSA / Prostate

Assessment (male > 40 years old)

Electrocardiograma/ Electrocardiogram

Placa de Pecho / Chest X Ray

Cernimiento Audivito / Hearing Screening

Cernimiento Visual / Visual Screening

Espirometria (Función Pulmonar) / Spirometry (Pulmonary function Test)

Cernimiento de Salud Mental / Mental Health Screening

Perfil de Riesgo Coronario / Coronary Risk Profile

Examen Físico – Physical Examination

Certifico que se me entregó y leí la Ley de Privacidad del Paciente, conocida por sus

abreviaturas, Ley HIPPA. / I certify that I received and read the Patient Privacy Act,

known by its initials, HIPAA Law.

___________________________________________________________________

Firma Fecha

INFORMACION PERSONAL PERSONAL INFORMATION

_______________________________________________________________________________________________________

APELLIDO PATERNO / LAST NAME MATERNO / MAIDEN NOMBRE / NAME INICIAL / INITIAL

Sexo/Sex ⃝ Femenino / Female ⃝ Masculino / Male Estado civil / Marital Status ____________

Fecha de Nacimiento /Date of birth Dia/Date _____ Mes/Month ____ Año / Year __________

Raza / Race ⃝ Blanca / White ⃝ Negra / black ⃝ Otra / Other

Religión / Religion _______________________ Etnicidad / Ethnicity : ⃝ Hispano ⃝ No hispano

Teléfono Residencial / Home Phone ( ) ___________________________

Teléfono Trabajo / Work Phone ( ) ___________________________

Celular / Cellular ( ) ___________________________

Correo Electrónico / Email address ______________________________________________________________

Empleador / Employer _________________________________________

Dirección Postal / Postal Address ______________________________________________________________

____________________________________________________________________________________________

Ciudad/City ____________________ Estado / State _________ Area Postal/ Zip Code __________________

Dirección Física / Physical Address (if different) _________________________________________________

____________________________________________________________________________________________

Ciudad/City ____________________ Estado / State _________ Area Postal/ Zip Code __________________

Contacto en caso de emergencia/ Contact in case of emergency ____________________________________

Relación / Relation __________________________________________________________________________

Teléfono / Telephone ( ) _______________________________

PLAN MEDICO/HEALTH INSURANCE

Plan Primario / Primary Plan ⃝ SSS ⃝ MCS ⃝ HUMANA ⃝ MAPFRE ⃝ OTRO: ________________

Asegurado principal / Primary assured __________________________________________________________

Relación con el paciente / relation with patient _________________________________________________

Plan Secundario / Secondary Plan ⃝ SSS ⃝ MCS ⃝ HUMANA ⃝ MAPFRE ⃝ OTRO: ____________

Asegurado principal / Primary assured __________________________________________________________

Relación con el paciente / relation with patient __________________________________________________

RESUMEN DE HISTORIAL MÉDICO MEDICAL HISTORY SUMMARY

APELLIDOS/

Last Name

NOMBRE

NAME

FECHA DATE

Por favor, marque los encasillados de aquellas condiciones o enfermedades que ha padecido o que padece en el presente. Please, make a mark on the boxes for those conditions or illnesses you have suffered.

Dolor de cabeza frecuente / Frequent headaches

Fractura de cráneo / Skull Fracture

Pérdida del conocimiento / Loss of consciousness

Pérdida de memoria / Memory loss

Convulsiones / Seizures

Visión doble / Double vision

Ardor en la vista / Burning sensation in the eyes

Lagrimación frecuente / Frequent lacrimation

Irritación en los ojos / Eye irritation

Infecciones de oído frecuentes / Frequent ear infections

Pérdida de audición / Hearing loss

Silbido en los oídos / Ringing in the ears

Alergia nasal / Nasal allergy

Sangrado nasal frecuente / Frequent nasal bleeding

Sinusitis frecuente / Frequent sinusitis

Mareos frecuentes / Frequent dizziness

Hipertiroidismo / Hyperthyroidism

Hipotiroidismo / Hypothyroidism

Asma / Asthma

Bronquitis / Bronchitis

Tuberculosis

Pulmonía / Pneumonia

Tos persistente / Persistent coughing

Flema con sangre / Phlegm with blood

Falta de aire / Shortness of breath

Fatiga durante la noche / Nocturnal fatigue

Palpitaciones / Palpitations

Dolor de pecho / Chest pain

Infarto cardiaco / Myocardial infarction

Hernia en el esófago / Esophageal hernia

Úlceras estomacales / Gastric ulcers

Úlcera duodenal / Duodenal ulcer

Náuseas o vómitos frecuentes / Frequent nausea or vomiting

Vómito con sangre / Blood vomiting

Dolor abdominal frecuente / Frequent abdominal pain

Ictericia (piel amarilla) / Jaundice (yellow skin)

Lesiones en la piel / Skin lesions

Hepatitis

Piedras en la vesícula / Gallbladder stones

Pancreatitis

Divertículos / Diverticulosis

Hemorroides / Hemorrhoids

Estreñimiento / Constipation

Diarrea frecuente / Frequent diarrhea

Sangre en la excreta / Blood in feces

Hernia inguinal / Inguinal Hernia

Hernia abdominal / Abdominal hernia

Masas en el cuello / Neck masses

Nódulos agrandados / Enlarged nodules

Ronquera frecuente / Frequent voice hoarseness

Infecciones de garganta / Throat infections

Problemas con las encías / Gum problems

Infecciones de orina / Urinary infections

Cistitis frecuente / Frequent cystitis

Infecciones en los riñones / Kidney infections

Piedras en los riñones / Kidney stones

Sangre en la orina / Blood in urine

Agrandamiento de la próstata / Prostate enlargement

Infecciones de la próstata / Prostate infections

Infecciones venéreas / Venereal infections

Disminución en el flujo de orina / Decreased urinary stream

Coyunturas dolorosas / Painful joints

Dolor en los brazos / Pain in the arm

Dolor en las piernas / Leg pain

Adormecimiento de los pies / Feet numbness

Adormecimiento de las piernas / Leg numbness

Adormecimiento de las manos / Hand numbness

Flebitis / Phlebitis

Dolor de espalda / Back pain

Discos herniados / Vertebral disk herniation

Calambres nocturnos / Nocturnal cramps

Venas varicosas / Varicose veins

Problemas de circulación / Circulatory problems

Transfusiones de sangre / Blood transfusions

Anemia

Presión sanguínea alta / High blood pressure

Diabetes, desde cuándo: / Diabetes, since when:

Colesterol elevado / High cholesterol

Triglicéridos elevados / Increased triglycerides

Ácido úrico elevado /High uric acid

Sobrepeso sobre 15 libras / Overweight more than 15 lbs.

Pérdida de peso anormal / Abnormal weight loss

Hace ejercicio regularmente / Exercise regularly

Pérdida de apetito / Loss of appetite

Fiebre recurrente / Recurrent fever

Fiebre nocturna / Nocturnal fever

Sudores nocturno / Night sweat

Fuma, desde cuando: ; cuántos al día:

Smoke, since when: ; how many a day:

Consume alcohol, cuántos tragos semanales:

Alcohol consumption; how many drinks a week:

RESUMEN DE HISTORIAL MÉDICO (Continuación) MEDICAL HISTORY SUMMARY (Continuation)

Alergias a alimentos / Food allergies: Alergias a medicamentos / Drug allergies:

Cirugías / Surgeries: Medicamentos que está tomando / Current medication:

HISTORIAL FAMILIAR / FAMILY HISTORY

Muerte súbita / Sudden death

Infarto cardiaco / Cardiac infarction

Presión sanguínea alta / Blood high pressure

Diabetes

Cáncer de seno / Breast cancer

Cáncer del colon; Colon cancer

Cáncer de la próstata / Prostate cancer

Tuberculosis

Otro, especifique:

Other, specify:

HISTORIAL DE VACUNACIÓN / IMMUNIZATION HISTORY

Pulmonía / Pneumonia

Influenza

Tétano / Tetanus

Sarampión / Measles

Varicela / Chicken pox

Papera / Mumps

Hepatitis: ¿cuál? A B

Otro, especifique:

Other, specify:

SÓLO PARA FÉMINAS / FOR FEMALES ONLY

Dolor en los senos / Breast Pain Raspes / Dilation & Curettage (D&C)

Masas en los senos / Breast masses Cirugía de la útero / Uterine surgery

Cirugía o biopsia de seno / Breast surgery or biopsy Cirugía de los ovarios / Ovarian surgery

Menstruación normal / Normal menstruation Toma suplementos de calcio / Take calcium supplements

Menstruación dolorosa / Painful menstruation Toma reemplazo hormonal / Take hormonal substitute. ¿Cuál? / Which one? Menstruación prolongada / Prolonged menstruation

Colonoscopía / Colonoscopy Fecha/Date

Número de embarazos / Number of pregnancies: Número de partos / Number of deliveries:

Número de abortos / Number of abortions: Número de cesáreas / Number of C-sections:

Última menstruación / Last menstrual period: Última mamografía / Last mammogram: Fecha / Date:

SÓLO PARA VARONES / FOR MEN ONLY

Examen rectal de la próstata / Rectal prostate exam: Fecha / Date:

Colonoscopía / Colonoscopy: Fecha / Date:

Perfil de Riesgo Coronario / Coronary Risk Profile Página / Page 1

PERFIL DE RIESGO CORONARIO / CORONARY RISK PROFILE Por favor, escriba en letra de molde. / PLEASE PRINT

Apellidos Last Name(s)

Nombre Name

Inicial Middle Initial

Fecha De Nacimiento Date of Birth

Sexo Gender

M F Peso Weight

Estatura Height

Raza Race

Caucásica / White Afro-americana / African-American Hispano / Hispanic

Asiático / Asian Nativo americano / Native American Otro / Other:

Dirección

Ciudad City

Estado State

Código Postal Zip Code

# Teléfono del Hogar Home Telephone #

# Teléfono del Trabajo Work Telephone #

Dirección De Correo Electrónico E-Mail Address

HISTORIAL DE SALUD / HEALTH HISTORY

Familiar / Family: Haga una marca en cualquier problema de salud que ha tenido su familia (padre, madres, hermano o hermana). Make a mark on any health problems found in your family (father, mother, brother or sister)

Diabetes

Infarto antes de los 65 años de edad Stroke before the age of 65

Enfermedad coronaria, infarto cardiaco o cirugía coronaria antes de los 55 años de edad para varones, 65 años de edad para las féminas Coronary heart disease, heart attack or coronary surgery before the age of 55 for men, 65 for women

Obesidad / Obesity

Colesterol alto / High cholesterol Presión arterial alta / High blood pressure

Historial de Salud Personal / Personal Health History: Haga una marca en cualquier problema de salud que su médico le haya dicho que tiene. / Make a mark on any health problem your physician has told you that you have.

Enfermedad coronaria, angina (dolor de pecho), ataque cardiaco, cirugía coronaria de desviación arterial, marcapasos, desfibrilador, colocación de stent, o angioplastia

Coronary heart disease, angina (chest pain), a heart attack, coronary artery bypass surgery, pacemaker, defibrillator, stent placement or angioplasty

Fallo cardiaco congestivo Congestive heart failure

Arritmia (latidos rápidos e irregulares del corazón Atrial fibrillation (rapid, irregular heartbeat)

Síncope o flujo sanguíneo restringido a la cabeza Stroke or restricted blood flow to head

Ataques isquémicos pasajeros (señales de aviso de síncope) Transient ischemic attack (stroke warning signs)

Dolor en la pantorrilla mientras camina que cesa con descanso Pain in calf when walking that stops with rest

Colesterol sanguíneo alto (240+ mg/dL o 6.2 mmol/L) High blood cholesterol (240+ mg/dL o 6.2 mmol/L)

Presión arterial alta (140/90+) High blood pressure (140/90+)

Diabetes Diabetes

Bronquitis crónica o enfisema (COPD) Chronic bronchitis or emphysema (COPD)

Tos crónica (3 semanas o más) Chronic cough (3 weeks or more)

Asma (jadeo, tos, dificultad para respirar) Asthma (wheezing, coughing, difficulty breathing)

Corto de respiración al ejercitarse Shortness of breath with exertion

Medicamentos / Medications. Marque cualesquiera medicinas que toma regularmente. / Mark any medicines you take regularly.

Nitroglicerina, para el dolor de pecho / Nitroglycerine, for chest pain Medicina para la presión alta / Blood pressure medicine

Aspirina / Aspirin Anticoagulante (diluyente sanguíneo) / Anticoagulant (blood thinner)

Medicina para bajar el colesterol / Cholesterol-lowering medicine Medicina para la Diabetes / Diabetes medicine

Estrógeno, hormonas femeninas / Estrogen, feminine hormones Medicina para el asma, COPD / Asthma, COPD medicine

Otro / Other:

Historial de Fumador / Smoking History Indique sus prácticas actuales de fumador / Indicate your present smoking practices.

Nunca ha fumado / Never smoked Dejó de fumar hace más de un año / Quit smoking more than a year ago

Fuma cigarrillos actualmente / Currently smoke cigarettes Dejó de fumar durante el pasado año / Quit smoking within the last year

Fuma una pipa o cigarro solamente / Smoke a pipe or cigar only

Fumador de segunda mano / Secondhand smoke: ¿Está usted expuesto a humo de segunda mano regularmente en el hogar o en el trabajo? Sí No Are ;you exposed to secondhand smoke regularly at home or at work? Yes No

Actividad Física / Physical Activity

Ejercicio aeróbico: ¿Cuántas días a la semana acumula usted por lo menos 30

minutos de actividad física como caminar ligero, ciclismo, trotar, nadar, jardinería activa o deportes activos?

Aerobic exercise: How many days each week do you accumulate at least 30

minutes of physical activity such as brisk walking, cycling, jogging, swimming, active gardening or active sports?

Ningún ejercicio regular Un día Dos días No regular exercise One Two

De tres a cuatro días Cinco días Three to four Five or more

Actividades moderadas: ¿Cuánto tiempo pasa usted semanalmente en actividades

moderadas (caminar ligero, correr bicicleta hasta 10 mph, baile aeróbico, etc.)? Moderate Activities.: How much time each week do you spend doing moderate

activities (e.g. brisk walking, bike up to10 mph, aerobic dance)?

Ninguna actividad regular ½ hora 1 hora No regular activity ½ hour 1 hour

2 horas 3-4 horas 5 horas o más 2 hours 3-4 hours 5 or more hours

Actividades vigorosas: ¿Cuánto tiempo pasa usted semanalmente en actividades

vigorosas (correr, correr bicicleta hasta 12 mph o más, deportes activos)? Vigorous Activities.: How much time each week do you spend doing vigorous

activities (e.g. running, bike up to12 or more mph, active sports)?

Ninguna actividad regular ½ hora 1 hora No regular activity ½ hour 1 hour

2 horas 3-4 horas 5 horas o más 2 hours 3-4 hours 5 or more hours

Perfil de Riesgo Coronario / Coronary Risk Profile Página / Page 2

Restricción de ejercicio. ¿Le ha restringido un médico la actividad por razones de salud? Sí No

Exercise Restriction. Has a doctor restricted your activity for health reasons? Yes No

Hábitos alimenticios / Eating Practices

Comidas regulares.

¿Omite el desayuno u otras comidas regularmente? Sí No

Regular meals. Do you often skip breakfast or other meals? Yes No

Panes/granos. ¿Cuántas porciones de panes o cereales integrales consume usted diariamente (porción = 1 rebanada de pan; 1 taza de cereal seco; ½ taza de cereal cocido; ½ taza de arroz integral)?

Breads/Grains. How many servings of whole grain bread or cereals do you eat daily

(serving = 1 slice bread; 1 cup dry cereal; ½ cup cooked cereal; ½ cup of brown rice?

Ninguna Una Dos Tres Cuatro 5 o más None One Two Three Four 5 or more

Frutas. ¿Cuántas porciones de frutas consume usted diariamente (porción = 1 taza

fresca; ½ taza cocidas; 6 onzas de jugo)? Fruits. How many servings of fruits do you eat daily (serving = 1 cup fresh; ½ cup

cooked; 6 oz of juice?

Ninguna Una Dos Tres Cuatro o más None One Two Three Four or more

Vegetales. ¿Cuántas porciones de vegetales consume usted diariamente (porción =

1 taza crudos; ½ taza cocidos; 6 onzas de jugo de vegetales; 1 ensalada mediana)? Vegetables. How many servings of vegetables do you eat daily (serving = 1 cup raw;

½ cup cooked; 6 oz of vegetable juice; 1 medium salad)?

Ninguna Una Dos Tres Cuatro 5 o más None One Two Three Four 5 or more

Alimentos refinados. ¿Cuántas veces al día consume usted alimentos altamente

refinados y meriendas típicas (bebidas carbonatadas, chips, papitas fritas, postres, galletas, bizcocho u otros dulces)?

Refined Foods. How times a day do you eat highly refined foods and typical snacks

(soda pop, chips, fries, pastry, cookies, cake or other sweets)?

Ninguna Una Dos Tres Cuatro 5 o más None One Two Three Four 5 or more

Grasas. Marque cualquiera de las siguientes grasas o alimentos altos en grasas que

usted típicamente consume (incluyendo los que usa al cocinar). Fats. Mark any of the fats or high fat foods below that you typically eat (including

those used in cooking?

Mantequilla Margarina en barra Margarina libre de ácidos trans-grasos Aderezo para ensalada en aceite o mayonesa Aceites vegetales (i.e., oliva, canola, soya) Manteca o jugo de la carne Nueces, semillas o mantequilla no hidrogenada de maní Aceitunas o aguacate

Butter Stick margarine Trans fatty acid free margarine Oil-based salad dressing or mayonnaise Vegetable oils (e.g., olive, canola, soy) Shortening, lard or meat drippings Nuts, seeds or non-hydrogenated nut butters Olives or avocados

Carnes. ¿Qué clase de carne consume usted usualmente? Meats. What type of meat do you usually eat?

Carnes rojas mayormente incluyendo bistec, hamburguesa, hot dog, tocineta, salchichas o pollo frito.

Primarily read meats including steak, hamburger, hot dog, bacon, sausage or fried chicken

Rara vez carne roja o limitado a cortes magros, o come pollo sin piel o pescado Seldom eat red meat or limit it to only lean cuts, or eat skinless poultry or fish

Rara vez come carne, come alimentos mayormente sin carne (alimentos vegetarianos de proteína)

Seldom each any meats, eat primarily meatless entrees (vegetarian protein foods)

Huevos. ¿Cuántas yemas de huevo consume usted semanalmente (incluyendo las que usa al cocinar)?

Eggs. How many egg yolks do you each week (including those used in cooking)?

Ninguna Una Dos Tres Cuatro 5 o más None One Two Three Four 5 or more

Nueces y semillas. ¿Cuántas porciones de nueces, semillas o mantequilla no hidrogenada de maní consume usted semanalmente (1 porción = 1 oz de nueces o

semillas o 2 cucharadas de mantequilla de nueces)?

Nuts and Seeds. How many servings of nuts, seeds or non-hydrogenated nut butters do you eat weekly (serving = 1 oz of nuts or seeds, o 2 tablespoons of nut butter)?

Ninguna Una Dos Tres Cuatro 5 o más None One Two Three Four 5 or more

Productos lácteos. ¿Qué clase de productos lácteos usa usted usualmente? Dairy Products. What type of dairy products do you usually use?

leche regular, yogur, queso, crema agria

solamente productos lácteos sin grasa (o no lácteos)

consumo ambos

regular milk, yogurt, cheese, sour cream

only non-fat dairy products (or non-dairy

use both of the above

Legumbres. ¿Cuántas porciones (2/3 de taza) de habichuelas, guisantes o habichuelas de soya consume usted semanalmente?

Legumes. How may servings (2/3 cup) of beans, split peas or soybeans do you eat weekly?

Ninguna o menos de 1 1 ó 2 3 o más None or less than one 1 or 2 3 or more

Sal. ¿Añade usted a menudo sal a su comida en la mesa o come alimentos salados

(pepinillos, salsa soya, papitas) frecuentemente? Sí No

Salt. Do you often add salt to your food at the table and frequently eat salty foods

(pickles, soy sauce, chips)? Yes No

Bebidas con cafeína. ¿Cuántas bebidas con cafeína toma usted diariamente (café, té, colas)?

Caffeine Drinks. How many caffeinated beverages do you drink daily (coffee, tea, cola drinks)?

Ninguna Una Dos Tres Cuatro 5 o más None One Two Three Four 5 or more

Agua. ¿Cuántos vasos de agua toma usted diariamente? Water. How many glasses of water do you drink daily?

Menos de 3 3 a 5 6 a 7 8 o más Less than 3 3 to 5 6 to 7 8 or more

Comidas de restaurantes.

Cuando come afuera, ¿qué tipo de comidas ordena usted típicamente? Comidas altas en grasa: establecimientos de comida rápida, biftec, pollo frito, alimentos con salsas espesas, crema agria, queso, y postres suculentos O comidas más saludables: bajas en grasa y más vegetales, granos y frutas

Restaurant Meals. When you eat out, what type of meals do you typically order? High fat meals: fast food, steak, fried chicken, foods with rich sauces, sour cream, cheese, and rich desserts Or healthier meals: lower in fat and more vegetables, grains, and fruits

mayormente comidas altas en grasas

mayormente comidas más saludables o rara vez como afuera

como más o menos la misma cantidad de ambas

mostly high fat meals

mostly healthier meals or seldom eat out

eat both kinds about the same

Alcohol. ¿Cuántos bebidas alcohólicas toma usted en una semana?

(1 trago = 12 oz de cerveza, 5.5 oz de vino o 1.5 oz de licor)?

Alcohol. How many alcohol containing beverages do you drink in a typical week?

(1 drink = 12 oz of beer, 5.5 oz of wine or 1.5 of liquor)

rara vez o nunca tomo esas bebidas hasta 7 hasta 14 más de 14 rarely drink these beverages up to 7 up to 14 more than 14

Peso. Indique cualquier cambio de peso desde que tenía 21 años de edad

No he subido de peso o he aumentado menos de10 libras.

He aumentado de 10 a 19 libras.

He aumentado de 20 a 29 libras.

He aumentado de 30 libras o más.

Weight. Indicate any change in weight since you were about 21 years old.

I have not gained weight or gained less tan 10 pounds.

I have gained 10 to 19 pounds.

I have gained 20 to 29 pounds.

I have gained 30 pounds or more.

Perfil de Riesgo Coronario / Coronary Risk Profile Página / Page 3

Factores Mentales y Sociales / Mental and Social Factors

Las emociones y relaciones pueden tener un efecto sobre la salud cardiaca. Indique su situación. Emotions and relationships can have an effect on heart health. Indicate your situation.

Triste. ¿Se ha sentido triste e infeliz gran parte del tiempo

últimamente? Sí No Unhappy. Have you felt sad and unhappy much of the time lately? Yes No

Coraje. ¿Se ha sentido frustrado, molesto o con coraje gran parte del tiempo últimamente?

Sí No Anger. Have you felt frustrated, upset or angry much of the time lately?

Yes No

Apoyo social. ¿Tiene usted familiares o amigos a quienes les habla y con quienes socializa frecuentemente?

Sí No Social Support. Do you have family and friends you talk to and socialize with frequently?

Yes No

Comunidad. ¿Se reúne usted regularmente con un grupo que le da apoyo, alivio y significado en su vida?

Sí No Community. Do you meet regularly with a group that give you support, comfort, and meaning in your life?

Yes No

Sueño. ¿Duerme por lo general menos de 7 a 8 horas diariamente? Sí No Sleep. Do you usually get less than 7 to 8 hours of sleep daily? Yes No

Agotamiento. ¿Se siente usted cansado, agotado y exhausto gran parte del tiempo?

Sí No Fatigue. Do you feel tired, worn out, and exhausted much of the time?

Yes No

Mujeres solamente. Marque cualquier condición que aplique.

Actualmente embarazada Llegué a la menopausia.

Women only. Mark any condition that applies.

Currently pregnant Reached menopause

Preparación. ¿Está usted preparado para hacer cambios de estilo de vida para mejorar su salud en las siguientes áreas?

(Refiérase a las cinco descripciones listadas.)

1 Ningún interés actual en hacer cualquier cambio de estilo de vida 2 Considerando hacer un cambio de estilo de vida 3 Haciendo planes para lograr este cambio 4 Comencé recientemente a implementar este cambio. 5 Lo he estado haciendo por 6 meses o más.

Readiness. Are you ready to make lifestyle changes to improve your health in the following areas?

(Refer to the five descriptions shown.)

1 No present interest in making any lifestyle change 2 Thinking about making a lifestyle changes 3 Making plants to achieve this change 4 Recently started implementing this change. 5 Have been doing this for 6 months or more.

1 2 3 4 5 Comer diariamente alimentos saludables para el corazón 1 2 3 4 5 Eat heart-healthy meals daily

1 2 3 4 5 Dejar de fumar o continuar siendo un no fumador 1 2 3 4 5 Quit smoking or remain a non-smoker

1 2 3 4 5 30 minutos o más de actividad física, 3-4 + días a la semana 1 2 3 4 5 30 minutes or more of physical activity, 3-4+ days/per week

1 2 3 4 5 Lograr/mantener un peso saludable 1 2 3 4 5 Achieve/maintain a healthy weight

Fecha / Date:

La alianza de salud para su empresa

Millennium Park Plaza, #15 Second ST, suite 540 Guaynabo, PR 00968-1743 787-708-6777

www.prevencionpr.com

AUTORIZACION

Yo, _______________________, autorizo a Wellness Alliance a

enviar los resultados de la evaluación médica preventiva al correo

electrónico ___________________________________ de darse

alguna de las siguientes situaciones:

Resultados alterados que requieren atención inmediata

No poder asistir a mi cita de Entrevista Final luego de ser contactado

por el personal de Wellness Alliance

De no recibir contestación para coordinar su entrevista final luego de

ser contactado en más de tres ocasiones.

______________________ ______________

Firma Fecha

Número Récord: _________________

De no tener correo electrónico se enviaran sus resultados por correo postal.

NOTICE OF PRIVACY PRACTICES FOR THE PROTECTION OF PROTECTED HEALTH INFORMATION THAT IDENTIFIES THE INDIVIDUAL

This notice describes how your protected health Information might be used and disclosed and how You can obtain access to the same. Please, review it carefully.

OUR LEGAL RESPONSIBILITY Wellness Alliance is committed to safeguard your Protected Health Information. We are required by Law to maintain the privacy and confidentiality of your protected health information (PHI) and to provide you with this notice of our legal duties and privacy practices with respect to protected health information.

This notice will be effective on December 1, 2008, and will remain effective until we revise it. WELLNESS ALLIANCE will abide by the terms the notice currently in effect.

Wellness Alliance reserves the right to change our privacy practices and the terms of this notice. Before we make a significant change in our privacy practices, we will change this notice and send an updated notice to our active subscribers.

Protected Health Information is information that can identify you (name, last name, social security number); including demographic information (like address, zip code), obtained from you through a request or other document in order to obtain a service, created and received by a health care provider, a medical plan, intermediaries who submit claims for medical services, business associates, and that is related to (1) your health and physical or mental condition, past, present, or future; (2) the provision of medical care to you, or (3) past, present, or future payments for the provision of such medical care. In this Notice, this information will be called protected health information. This Notice of Privacy Practices has been written and amended so that it will comply with HIPAA Privacy Regulations. Any term not defined in this Notice will have the same meaning that it has in the HIPAA Privacy Regulation.

Main Uses and Disclosures of Protected Health Information In order to perform our duties as insurance or benefit administrator, we may use or disclose information for medical treatment, payment of medical services, and health care operations; for example:

Treatment. For the provision, coordination, or supervision of your medical care, and other related services. For example, the plan may disclose medical information to your health care provider for treatment, if so requested.

Payment .To collect or provide payment for medical care, including collections and claims handling. For example, the plan may use or disclose protected health information in order to pay claims for health services rendered, or to provide eligibility information to your health care provider when you receive treatment.

Health Care Operations. For legal purposes and audit processes, including fraud and abuse detention and compliance, as well as the planning and development of businesses and administrative activities and management of businesses. We may use or disclose medical information to another entity related to you and that is also subject to the federal or local rules.

Gathered Information Wellness Alliance has the commitment to limit the information that we gathered to the strictly necessary for the administration of your insurance coverage or benefit. Within our functions of administration, we gathered personal information that you provide in application forms and other documents, transactions with us or with our affiliated companies, credit agencies, and information of health care providers, for example post service claims.

Covered Entities To perform our duties as a health care service provider, Wellness Alliance may use or disclose protected health information.

Business Associates We contract with persons and organizations (business associates) so they can perform certain functions in our name, or to provide certain types of services. In

order to perform these functions or provide these services, business associates may receive, create, maintain, use, or disclose protected health information, but only after they agree in writing to properly safeguard such information. Among the examples of business associates are institutions that offer claims processing, certain accounting activities (CPA), and technical support for medically oriented computer software.

Other Covered Entities We may use or disclose your protected health information in order to assist health care providers with the treatment they provide to you, or with payment activities concerning you. For example, we may disclose or share your protected health information in order to coordinate benefits. We may disclose your protected health information to a health care professional if he or she provides you with treatment.

Other Possible Uses and/or Disclosures of Your Protected Health Information Required by Law. We may use or disclose your protected health information whenever Federal, State, or Local Laws require its use or disclosure. In this Notice, the phrase “as required by Law” is defined the same as it is defined in HIPAA Privacy Standards.

Public Health Activities. We may use or disclose your protected health information for public health activities, including the statistical report on illnesses and vital information, among others.

Health Oversight Activities. We may use or disclose your protected health information to those government agencies that regulate health care related activities.

Food and Drug Administration (FDA). We may use or disclose your protected health information to the FDA in order to prevent to the health or national security in relation to adverse events related to food, supplements, products and product defects, among others.

Abuse Or Neglect. We may use or disclose your protected health information to a government official authorized to receive reports of abuse or neglect against minors or adults or domestic violence situations.

Legal Proceedings. We may use or disclose your protected health information during the course of any judicial or administrative proceedings: (i) in response to an order of a court or administrative tribunal (provided that the covered entity discloses only the protected health information expressly authorized by such order); or (ii) in response to a subpoena, discovery request, or other lawful process.

Law Enforcement Officials. We may use or disclose your protected health information to law enforcement officials. We may use or disclose your protected health information for research purposes. In addition to: Correctional institutions in the case of inmates; as authorized by laws relating to workers’ compensation (Corporacion del Fondo del Seguro del Estado); disaster relief efforts, so that your family may be provided with information about your health condition, and your location.

Other persons participating in your health care. Unless request a restriction (in accordance with the procedure described later in this Notice of Privacy Practices, under “Right to request a restriction”) we may disclose limited protected health information to a friend or family member who is involved with your care, or who are responsible for payment of medical services. If you are not in person, if you are disabled, or it is an emergency, we will use our professional judgment in the disclosure of information that we understand will be in your better interest.

Disclosures to an Authorized Representative. We will disclose your protected health information to a person designated by you as your authorized representative, and who qualifies for this designation in accordance with applicable laws of the Commonwealth of Puerto Rico. However, before we disclose protected health information to your authorized representative, you must provide us with a written document designating this person as such, along with any other support documents (like a power of attorney). Even when you designate an authorized representative, HIPAA Privacy Regulations allow us not to treat this person as your authorized representative if, in our professional judgment, conclude that: (i) you have been or may be subject to domestic violence, abuse, or neglect by such person; (ii) treating such person as your authorized representative could endanger you, or (iii) we, in the exercise of professional judgment, decide that it is not in your best interest to treat this person as your authorized representative. With your authorization: You may authorize us in writing, to use or disclose your protected health information to other persons, for any other purpose. The authorization must be signed and dated by you, it must indicate the person or entity authorized to receive the information, a short description of the information been disclosed, and expiration date for the authorization, which will not exceed two years from the date on which the document is signed. You have the right to revoke the authorization in writing, and the revocation will be in effect for future uses and disclosures of your protected health information. Nevertheless, your revocation will not apply to information that we have already used or disclosed. Unless you submit a written authorization, we may not use or disclose your protected health information for any other reason not described in this Notice.

RIGHT TO PRIVACY

You have the following rights regarding your protected health information. Right to Request a Restriction You have the right to request a restriction to the protected health information that we maintain at Wellness Alliance, and that we use or disclose for treatment, payment, or health care operations. Nevertheless, we are not required by Law to agree to any restriction that you request. If we agree to a restriction, we will comply with the same, unless the information is needed in order to provide you with emergency treatment. You may request a restriction by completing a request form, available at our service centers and through our Internet site. This form must be signed and approved by an authorized official. Right to Confidential Communications You may request that we communicate with you concerning your protected health information using an alternate method or physical location. For example, you may request that we contact you only at your work address, or use only your work phone number. You may request confidential communications by completing a request form, available at our service centers and through our Internet site. Right to Access You have the right to inspect and copy your personal, financial, insurance, or health information, within the limits and exceptions provided by law. In order to access your information, you must submit a written request to the Wellness Alliance’s Security and Privacy Department. You may obtain the request form at our service centers or through our Internet site. The first report that you request will be free. We reserve the right to charge a fee for subsequent copies. We may deny access to inspect or copy your protected health information under certain limited circumstances. If we deny you access to your information, you

may request a review of our denial. In order to request a review, you must contact our Office at the address on this Notice of Privacy Practices. An authorized official will review your request, and denial. Right to Amend If you believe that your protected health information, and that we keep in our files and/or systems, is incomplete or incorrect, you may request that we amend it. You may request to amend your protected health information by completing a request form, available at our service centers or through our Internet site. Your request must include an explanation or evidence to justify an amendment. Your request may be denied. If your request is denied, we will provide you with a written explanation for this denial. Right to an Accounting of Disclosures You have the right to request an accounting of certain disclosures of your protected health information made by MCS, for events not related to medical treatment, payment for medical services, health care operations, or in compliance with your authorization. You may request an accounting of disclosures by completing the request form available at our service centers or through our Internet site. Right to a Printed Copy of this Notice You have the right to obtain a paper copy of this Notice of Privacy Practices at your request, even after agreeing to receive a copy of the same in electronic form.

COMPLAINTS

If you understand that we have incurred in any violation of your privacy rights, or if you disagree with our decisions with regards to access to your protected health information, you have the right to submit a complaint to the address at the end of this Notice. Likewise, you may file a complaint with the Secretary of Health and Human Services (DHHS), at the following address: Region II, Office for Civil Rights, US Department of Health and Human Services (DHHS) Jacob Javits Bldg., 26 Federal Plaza, Suite 3312, New York, 10278; telephone: 1-866-627-7748, or the Internet address: www.hhs.gov/ocr/hipaa. Your complaint should include: (1) the name of the covered entity you are filing a complaint against; (2) brief description of the alleged violation, and (3) file the complaint within 180 days of when the complainant knew of should have known that the act or omission complained of occurred. At Wellness Alliance, we believe in the privacy of our clients protected health information. We will not penalize nor retaliate against you for filing a complaint with the Department of Health and Human Services, or with Wellness Alliance.

CONTACT INFORMATION FOR WELLNESS ALLIANCE

You may request additional information about this Notice of Privacy Practices, or file a complaint with Wellness Alliance at the following address:

WELLNESS ALLIANCE Attention: Privacy Officer

Millennium Park Plaza • 15 2nd Street • Suite 540 Guaynabo, PR 00968

787-708-6777

www.wellnessalliancepr.com www.prevencionpr.com

EFFECTIVE DAY This Notice of Privacy Practices is effective on December 1, 2008.