Medical History Form

Thank you for taking the time to fill out this questionnaire.

This will allow us to address your concerns and explain what Sanoviv can do for you. After submitting this form, please contact your admissions coordinator to schedule the date and time of your call.

* First Name

 

Middle name

 

* Last Name

 

Gender

Male Female

Date of birth

 dd   yyyy: 

* Address

 

* City

 

Country

Zip/ Postal Code

 

Occupation (Please write up to four words).

 

Preferred phone number to receive Sanoviv´s call, please include the country code, area code and phone number.

* Home Phone   * Cell
Skype account

* Email Address

 

Marital Status

 

Religion

 

Person to contact in case of emergency

 

Phone number of contact person

 

Relationship with contact person

 

What is your primary language?

 

Do you require translation in order to communicate in English?

Yes No

How did you hear about Sanoviv?

Online Search Friend, Relative
Doctor Referral USANA
In a Lecture In a Magazine, Books
Other

Please summarize your current health status.

 

What is the diagnosis that you have received? (Please include date of the diagnosis). If you do not have a diagnosis, what are your main health issues?

 

What do you want to achieve at Sanoviv?

 

In your opinion, What might have contributed or caused some of your main health complaints? Did anything significant happened in your life close to the time of onset?

 

Describe briefly the chronological evolution of your symptoms or/and diagnosis. Please include dates if possible.

 

What treatments have you done in the past and which ones are you currently receiving? Please specify dates if possible.

 

How physically independent are you?

Totally independent I need help from others to move from one place to another

Have you had any medical tests recently? If yes, please list the name of the test, date, and result.

 

What do your doctors say about your condition?

 

Do you have any known food allergies (that will cause an anaphylactic reaction)

No Yes

Do you have any known food sensitivities (those that may cause mild reactions)

No Yes

Please note any food allergies or sensitivities for your companion, if applicable

 

Have you ever been hospitalized for mental/emotional problems?

Yes No

Do you have any sensitivities or allergies to medication?

Yes No

Have you had any surgery? if yes, elaborate.

 

Have you ever been diagnosed with an infectious disease?

Yes No

In case of cancer, what types of chemotherapy or other treatments have you had?

 

Are you taking any medication or nutritional supplements? Please describe.

 

Are you taking any amphetamines (Adderall), Benzo (Valium, Xanax), or any antidepressant medications?

 Yes
 NO

Do you smoke or vape, or use tobacco, cannabis, or other addictive substances?

Yes No
Yes


 

Privacy Notice and Policy Statement

Dear owner of personal data:

This Privacy Notice (hereinafter the "Privacy Notice") is given in compliance with Article 3 section VI, 9, 15, 16, 17 and other applicable provisions of the Federal Law on Protection of Personal Data Held by Private Parties (hereinafter the "Law"), to inform you about your rights relating to the management, update, transfer and control of personal data, including sensitive personal data (hereinafter "Personal Data") held by the responsible organization identified below.

RESPONSIBLE ORGANIZATION IDENTIFICATION:

Name: AMAREVITA S. de R.L. de C.V. (hereinafter "AMAREVITA" and/or "Responsible")
Address: KM. 39 39 Carretera Libre Tijuana-Ensenada, sin número Playas de Rosarito, Baja California, C.P. 22710, en los Estados Unidos Mexicanos.

GATHERING AND USE OF PERSONAL DATA.

AMAREVITA gathers Personal Data when you fill a contact form online, request a medical consultation, or communicate with an admissions representative. When you do so, AMAREVITA gathers the following personal data: full name, nickname, gender, date of birth, full address, occupation, phone numbers contact, skype account, e-mail address, payment information, marital status, language, clothing size, transportation or travel information, name, phone and relationship of a person to contact in case of emergency, as well as information about how you heard about AMAREVITA. Likewise, AMAREVITA gathers the following sensitive personal data:: race, religious preferences, summary of medical history, health status, medical diagnoses, medical tests, medical treatment history, physical status, mental illness history, mental status (including whether or not you have ever been hospitalized for mental or emotional problems), allergies, dietary needs, infectious illnesses, and your exposure to current or past use of medications or supplements, including use of alcohol, tobacco or drugs, and family medical history.
When you have medical consultations and answer questions about your medical history, we save all your answers in Promedicis (our electronic health record system). If you provide copies of medical records, they may be stored electronically, on paper, or in another media format.
AMAREVITA uses, manages and stores your Personal Data. This use of your Personal Data is intended for the following purposes: (I) To fulfill your request for health services, (II) To provide medical advice; (III) To contact you after departure for follow up; (IV) To inform you about special, events, and new products, (V) To create your Medical Records and process them in compliance with health regulations, (VI) for statistical and internal reporting, and (VII) To issue charges to your bank card when applicable.
The purposes indicated on the Subsections (I), (II), (III), (V), (VI) and (VII) are those which give origin and are necessary for the existence, maintaining and compliance regarding the relationship between you and AMAREVITA.
The purpose indicated in Subsection (IV) is for merchandising, publicity and commercial prospection.

AUTHORIZATION, TRANSFER AND DISCLOSURE OF PERSONAL INFORMATION

By signing this document, whether by hand, electronic signature, or authorization granted by any other authentication mechanism implemented by the Responsible for such effect, in compliance with article 9 of the Law, you authorize AMAREVITA to gather, store, process, and transfer your Personal Data only to affiliated organizations of the medical industry or sector, for purposes strictly necessary for your medical care. AMAREVITA may send your Personal Data to third parties only when (I) We have your consent thereon, (II) They are essential for the prevention, diagnosis, or treatment of any medical condition or delivery of health services and you are unable to grant the consent due to a medical condition, as established by the Health regulations and other applicable legal provisions, and that such data processing is performed by a person subject to professional security or equivalent obligation, or (III) By a court order or administrative authority order.

In accordance with Mexican law, we maintain an official medical file in Spanish for each patient admitted to AMAREVITA. This official document may not be released to the patient, or any other parties, unless required by a court order, or from administrative authority, in the jurisdiction of Playas de Rosarito, Baja California, Estados Unidos Mexicanos. Patients may have access to medical test results, doctor discharge notes, and doctor recommendations, but they may not have access to the full official medical file.

UPDATES, ACCESS, AND PREFERENCES

In accordance with the provisions of the Law, you have the right to request Access to, Update (where inaccurate or incorrect), Cancel, or Oppose (where applicable) your Personal Data provided to AMAREVITA, object to the processing of your Personal Data, or Revoke the consent granted in accordance with the mechanisms provided by Law and that AMAREVITA has implemented, in which case we request you to contact the AMAREVITA´s Responsible Personal Data manager in writing by email or mail, as outlined below:

Name: AMAREVITA S. de R.L. de C.V.

Attention: Responsable de Manejo de Datos Personales

Address: Km.39 Carretera Libre Tijuana-Ensenada sin número, Playas de Rosarito, Baja California, C.P. 22710, Estados Unidos Mexicanos.

Phone Number: 52 (661) 614 9200

Email address: aftercare@sanoviv.com

PRIVACY NOTICE

Please note that in order to process a request to access, update, cancel or revoke your personal data, the request must contain and be accompanied by at least the following: (I) The holder’s name and address or other means to respond to your request, (II) Documents that prove your identity or, where applicable, proof of legal representation on your behalf, (III) The clear and precise description of the personal data which you want to realize any of the above actions, and (IV) Any other item that facilitates the location of the personal data.

Once the request is made, AMAREVITA will issue a written response, in the terms provided by the Law, and in case it does not reply, or the reply is not satisfactory, you have the right to appear before the National Institute of Transparency, Access to Information and Protection of Personal Data to request its intervention. Also, note that requests for deletion, modification, or access to medical or clinical records cannot be carried out under the provisions of the Health Law because AMAREVITA is obligated to keep these records active and confidential in our database for the term provided by Health Law for that purpose. AMAREVITA will allow you to update your personal information, not including medical records, including whether you want AMAREVITA to contact you about services and new offers.

SECURITY

AMAREVITA, in accordance with the Law, will establish and maintain appropriate administrative, technical, and physical strategies designed to protect your Personal Data against damage, loss, alteration, destruction, or unauthorized access. To make your personal data secure, as well as our medical and clinical records, we have implemented a system that provides access only to users and computers with valid passwords and credentials.

CHANGES TO THIS PRIVACY NOTICE

AMAREVITA may amend this privacy notice from time to time. If we make any substantial changes to the way we use your Personal Data, we will notify you by posting a prominent announcement on our web page or by email notification to the email address you provided to us.

Aviso de privacidad y declaración de política

Estimado propietario de la información personal:

Este Aviso de Privacidad (en adelante, el "Aviso de Privacidad") se otorga de conformidad con el Artículo 3 fracción VI, 9, 15, 16, 17 y otras disposiciones aplicables de la Ley Federal de Protección de Datos Personales en Posesión de los Particulares (en adelante la "Ley"), para informarle acerca de sus derechos relacionados con la gestión, actualización, transferencia y control de sus datos personales, incluyendo datos personales sensibles(en adelante, "Datos Personales") mantenidos por la organización responsable identificada a continuación.

IDENTIFICACIÓN DE LA ORGANIZACIÓN RESPONSABLE:

Nombre:: AMAREVITA S. de R.L. de C.V. (en adelante "AMAREVITA" /o "Responsable")
Domicilio:: KM. 39 Carretera Libre Tijuana-Ensenada, sin número Playas de Rosarito, Baja California, C.P. 22710, en los Estados Unidos Mexicanos.

 

RECOPILACIÓN Y USO DE LOS DATOS PERSONALES.

AMAREVITA recopila de Usted Datos Personales cuando usted llena un formulario de contacto en línea, solicita una consulta médica o se comunica con un representante de admisiones. Cuando lo hace, AMAREVITA recopila de usted Datos Personales generales consistentes en; nombre completo, sobrenombre, genero, fecha de nacimiento, domicilio completo, ocupación, números telefónicos de contacto, cuenta de Skype, dirección de correo electrónico, información de medios de pago, estado civil, idioma, talla de vestimenta, información relevante de transportación o viaje, nombre, datos de contacto y tipo de relación con terceras personas que puedan ser contactadas en caso de emergencia, e información sobre como escucho de AMAREVITA. Asimismo, AMAREVITA recopila de usted datos personales sensibles, consistentes en: raza, preferencias religiosas, resumen de historial médico, estado de salud actual, diagnósticos médicos, exámenes médicos, historial de tratamientos médicos, estado físico, historial médico sobre enfermedades mentales, estado mental (incluyendo si usted ha sido o no hospitalizado por problemas mentales o emocionales), alergias, necesidades dietéticas, enfermedades infecciosas, y su exposición a las mismas, uso de medicamentos o suplementos, incluyendo la ingesta de alcohol, tabaco, o alguna droga, y el historial médico de su familia.

Cuando tiene consultas médicas y responde preguntas sobre su historial médico, guardamos todas sus respuestas en Promedicis (nuestro sistema de registro de salud electrónico). Si usted provee copias de registros médicos, estos pueden ser guardados electrónicamente, en papel, o en cualquier otro formato.

AMAREVITA utiliza, gestiona y almacena sus Datos Personales. Este uso de sus Datos Personales está destinado a los siguientes propósitos: (I) Cumplir con su solicitud de servicios de salud, (II) Proporcionar asesoramiento médico; (III) Ponerse en contacto con usted después de su partida para el seguimiento; (IV) Para informarle sobre eventos especiales y nuevos productos, (V) Crear su Registro Médico y procesarlos de acuerdo con las regulaciones de salud, (VI) Para reportes estadísticos e internos, y (VII) Emitir cargos a su Tarjeta bancaria cuando sea aplicable.

Las finalidades indicadas en los incisos (I), (II), (III), (V), (VI) y (VII) anteriores, son aquellas que dan origen y son necesarias para la existencia, mantenimiento y cumplimento de la relación jurídica entre Usted y AMAREVITA.

La finalidad indicada en el inciso (IV) es aquella utilizada para fines mercadológicos, de publicidad y prospección comercial.

AUTORIZACION, TRANSFERENCIA Y DIVULGACION DE INFORMACION PERSONAL.

Al firmar este documento; ya sea a mano, con firma electrónica o autorización otorgada por cualquier otro mecanismo de identidad implementado por el Responsable, para tal efecto de conformidad con el artículo 9 de la Ley; autoriza a AMAREVITA a recopilar, almacenar, procesar y transferir sus Datos Personales sólo a organizaciones afiliadas de la industria y sector médico para fines estrictamente necesarios para su atención médica. AMAREVITA podrá enviar sus Datos Personales a terceros solamente cuando; (I) Tengamos su consentimiento al respecto, (II) Sean esenciales para la prevención, diagnóstico o tratamiento de cualquier condición médica o prestación de servicios de salud y Usted no pueda otorgarnos el consentimiento debido a alguna condición m&emedica;dica, de acuerdo a lo establecido en los reglamentos de salud y otras disposiciones legales aplicables, y que dicho procesamiento de datos sea realizado por una persona con garantía profesional o equivalente, y (III) Por Orden judicial o de Autoridad Administrativa.

De acuerdo a las leyes mexicanas, nosotros guardamos un archivo médico oficial en español para cada paciente admitido a AMAREVITA. Este documento oficial no puede ser entregado al paciente, o a terceros, al menos que sea requerido por una orden judicial, u otra autoridad administrativa, en la jurisdicción de Playas de Rosarito, Baja California, Estados Unidos Mexicanos. Los pacientes tienen acceso a los resultados de sus exámenes médicos, el alta del médico y las recomendaciones del médico, pero no tienen acceso al archivo médico completo oficial.

ACTUALIZACIONES, ACCESO Y PREFERENCIAS.

De acuerdo con las disposiciones de la Ley, Usted tiene el derecho de solicitar el Acceso a; Actualizar (cuando sea inexacto o incorrecto), Cancelar (si procede) sus Datos Personales proporcionados a AMAREVITA, Oponerse al procesamiento de sus Datos Personales, o Revocar el consentimiento otorgado de acuerdo con los mecanismos previstos por la Ley y que AMAREVITA ha implementado, en cuyo caso le pedimos que se comunique con el responsable de AMAREVITA por teléfono, por correo electrónico o por escrito como se indica a continuación:

Nombre: AMAREVITA S. de R.L. de C.V.

Atención: Responsable de Manejo de Datos Personales

Domicilio: Km.39 Carretera Libre Tijuana-Ensenada sin número, Playas de Rosarito, Baja California, C.P. 22710, Estados Unidos Mexicanos.

Número telefónico: 52 (661) 614 9200

Correo Electrónico: aftercare@sanoviv.com

AVISO DE PRIVACIDAD.

Tenga en cuenta que los requisitos para realizar una solicitud de Acceso, Actualización, Cancelación o Revocación de sus datos personales deberán contener e ir acompañados de al menos, lo siguiente: (I) El nombre y la dirección del titular y otros medios para responder a su solicitud, (II) Documentos que prueben su identidad o en su caso, prueba de representación legal en su nombre, (III) La descripción clara y precisa de los Datos Personales que desea realizar a cualquiera de las acciones anteriores, y (IV) Cualquier otro elemento que facilite la localización de los Datos Personales.

Una vez realizada la solicitud, AMAREVITA emitirá una respuesta por escrito, en los términos previstos por la Ley, y en caso de que no responda, o si la respuesta no es satisfactoria, usted tiene derecho a acudir ante el Instituto Nacional de Transparencia, Acceso a la Información y Protección de Datos Personales a solicitar su intervención. Asimismo, tenga en cuenta que las solicitudes de supresión, modificación o acceso a los registros médicos o clínicos no pueden llevarse a cabo de conformidad con las disposiciones de la Ley de Salud porque AMAREVITA está obligado a mantener estos registros activos en nuestra base de datos durante el plazo previsto por la Ley de Salud, para ese propósito AMAREVITA le permitirá actualizar su información personal, sin incluir los registros médicos, incluyendo, si desea; que AMAREVITA se comunique con usted acerca de los servicios y las nuevas ofertas.

SEGURIDAD

AMAREVITA, de acuerdo con la Ley, establecerá y mantendrá estrategias administrativas, técnicas y físicas apropiadas diseñadas para proteger sus Datos Personales contra daños, pérdida, alteración, destrucción o acceso no autorizado. Para proteger sus Datos Personales, así como nuestros registros médicos y clínicos, hemos implementado un sistema que proporciona acceso sólo a usuarios y procesadores con contraseñas y credenciales válidas.

CAMBIOS A ESTE AVISO DE PRIVACIDAD.

AMAREVITA puede reformar el aviso de privacidad política de tiempo en tiempo. Si realizamos cambios sustanciales en la forma en que utilizamos sus Datos Personales, le notificaremos publicando un anuncio en nuestra página de internet, así como una notificación por correo electrónico a la dirección de correo electrónico que usted nos proporcionó.

 

Terms of Use Agreement

Use of this website constitutes your acceptance of these Terms of Use. This Agreement describes the entire terms and conditions for use of Sanoviv.com.

Content Use and Ownership

All content on Sanoviv.com is copyrighted and you are not permitted to copy images, text, video, or other content from Sanoviv.com to be published or broadcast in any form, whether print or electronic, in any media or website. You may browse, print, and use the information for your own personal use only. All Sanoviv.com content is owned by AMAREVITA S. de R.L. de C.V., dba: Sanoviv Medical Institute, located in Baja California, México. By using this website, the user specifically agrees to be bound by the laws of Baja California, México and to be subject to the jurisdiction of the courts of the city of Playas de Rosarito, Baja California, México, expressly waiving any other jurisdiction or venue which may correspond to the user’s physical location when accessing the content, or for any other reason. Data collected at Sanoviv.com is handled according to our Privacy Notice and Policy, also available at Sanoviv.com.

Health or Medical Information

Sanoviv.com contains information about health practices or medical services that may be available at Sanoviv Medical Institute, located in Baja California, México. This content is for information/educational purposes only and is not intended to be used as a substitute for medical advice. Information contained on Sanoviv.com is not intended to be used to prevent, diagnose, treat, or cure any illness or condition. Recognizing that healthcare is an inexact science, Sanoviv does not guarantee any specific outcomes or results. Therefore, nothing on this website shall be construed as offering a promise or expectation of any result or outcome. Patient testimonials or stories shall in no way imply that your results will be similar. Individual results very from person to person.

Intended Audience

Sanoviv.com is an informational website that is primarily intended for residents or visitors of Baja California, México. Users who access this information in areas outside of Baja California, México specifically understand and acknowledge that services described may not be available in the area where they reside, and that accessing this information in no way represents a solicitation or recommendation to receive services that may not be available in their area. Information about medical treatments, diagnostics, or services should in no way be considered an attempt to practice medicine online, or in any jurisdiction other than Baja California, México. Patients who choose to travel to Baja California, México, will then be under the jurisdiction of the local laws.

Trade Name

The trade name “Sanoviv Medical Institute” along with Sanoviv trademarks, logos, and banners are the property of AMAREVITA S. de R.L. de C.V. You may use the name Sanoviv only in connection with links directed to a location within Sanoviv.com. You may not use our trade name “Sanoviv” or any other word or phrase combination which may be interpreted as use of our trade name.

Limitation of Liability

We will not be liable for indirect, special, or consequential damages (or any loss of revenue, profits, or data) arising in connection with this Agreement, even if we have been advised of the possibility of such damages. While we make every effort to verify the accuracy of our information and content, we will not be liable for errors or misrepresentations which may be present.

Disclaimers

We make no express or implied warranties or representations with respect to the use of information contained on Sanoviv.com. In addition, we make no representation that the operation of our site or sites will be uninterrupted or error-free, and we will not be liable for the consequences of any interruptions or errors. The laws of Baja California, México will govern this Agreement, without reference to rules governing choice of laws. Any action relating to this Agreement must be brought in the courts of the city of Playas de Rosarito, Baja California, México, and you irrevocably consent to the jurisdiction of such courts. You may not assign this Agreement, by operation of law or otherwise, without our prior written consent. Subject to that restriction, this Agreement will be binding on, inure to the benefit of, and enforceable against the parties and their respective successors and assigns. Our failure to enforce your strict performance of any provision of this Agreement will not constitute a waiver of our right to subsequently enforce such provision or any other provision of this Agreement. By browsing, viewing, or using Sanoviv.com in any way, you acknowledge that you have read this agreement and agree to all its terms and conditions.