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Salud Integral Treatment procedures

Medical Overview

In order for our medical staff to be able to accurately determine acceptability and proper dosage, patients will be required to submit their medical records to the offices of Salud Integral for review by our medical staff prior to being accepted for Anvirzel™ therapy.

Patients need to provide the completed Medical Overview Form and copies of their medical records that include physician report summaries of their current status and prognosis, medical history, evolution of disease and laboratory test results (Blood Work results and interpretations of Biopsy/Pathology, CAT Scans, MRI, PET etc.).

(Best completed in Google Chrome or Firefox Browser, you may get errors if viewed and completed in Internet Explorer Browser.)

Optionally, you may download, complete and return to us this PDF Version of the questionnaire.
PLEASE NOTE: The Adobe Acrobat Reader or similar is needed to open and view this file.

Patient Name*

Please enter the patient's name

Phone Number:*

Email:*

Please enter a valid email address

Age:*

Please enter the patient's age

Weight

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Height:

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Sex:*

MaleFemale

Please make a selection

Patient Address:*

Please enter your complete address here

Physician's Name:*

Please enter the physician's name here

Initial Diagnosis*

Please enter your initial diagnosis here

Date of Diagnosis*

Please enter date of diagnosis

Progression of the disease*

Please describe the progression of the disease

Current Treatment:*

Please describe your current treatment here

Other Medical Conditions:*

Please enter other medical conditions of patient here

Current Medications

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Are you taking cardiac glycoside digitalis or digoxin?

YESNO Invalid Input

Performance Status (Please check only one)*

100 Normal; no complaints, no evidence of disease.90 Able to carry on normal activity, minor signs or symptoms of disease.80 Normal activity with effort; some signs or symptoms of disease.70 Cares for self, unable to carry on normal activity or to do active work.60 Requires occasional assistance but is able to care for most of his needs.50 Requires considerable assistance and frequent medical care.40 Disabled; requires special care and assistance.30 Severely disabled; hospitalization is indicated, although death is not imminent.20 Very sick; hospitalization is necessary, active supportive treatment is needed.10 Moribund, fatal processes rapidly progress.

Please select one from list which best describes the performance status of the patient.

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