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YES |
NO |
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| 1. Are you in poor health..(meaning END STAGE DISEASE) |
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Está mal de salud |
| 2. Has there been any change in your general health within the past year |
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Ha cambiado su salud durante el último año |
| 3. My last physical was on / Mi último examen médico fue en
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| 4. Are you currently under the care of a physician |
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Está ahora bajo atención médica |
| If so, what is the condition being treated / Si es asi, que enfermeda se está curando
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| 5. The name and address of my physician is / El nombre y domicillio de mi médico es |
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| 6. Have you had any serious illness or operation |
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Ha tenido alguna operación o enfermedad seria |
| If so, what was the illness or operation / Si es asi, que operación o enfermedad
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| 7. Have you been hospitalized or had a serious illness within the past five years |
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Durante los últimos cinco (5) años ha sido hospitalizado ó ha tenido alguna enfermedad seria |
| If so, what was the problem / Si contesta afirmativamente explique
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| 8. Do you have or have you had any of the following diseases or problems |
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Tiene o ha tenido alguna de las siguientes enfermedades ó problemas |
| A. Damaged heart valves or artificial heart valves |
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Válvulas dañadas ó válvulas artificiales del corazon |
| B. Congenital heart lesions or murmurs |
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Lesión cardíaca congénita |
| C. Cardiovascular disease (heart trouble, heart attack, coronary insufficiency, coronary occlusion, high blood pressure, arteriosclerosis, stroke) |
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Enfermedad cardiovascular (enfermedad, del corazón, insuficiencia cardiaca, oclusión, coronaria, presión arterial alta, arteriosclerosis, sincope) |
| 1) Do you have pain in the chest upon exertion |
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Tiene dolor en el pecho cuando hace algún esfuerzo |
| 2) Are you ever short of breath after mild exercise |
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Después de hacer algún ejercicio siente faltarle el aire |
| 3) Do your ankles swell |
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) Se le hinchan los tobillos |
| 4) Do you get short of breath when you lie down, or do you require extra pillows when you sleep |
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Cuando se acuesta, siente que le falta aire para respirar ó necesita mas de 1 almohada para dormir |
| 5) Do you have a cardiac pacemaker |
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Tiene marcapasos cardíaco |
| D. Sinus trouble |
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Problema de senusitis |
| E. Asthma |
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Asma |
| F. Allergy |
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Alergia |
| G. Hives or skin rash |
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Ronchas ó salpullido |
| H. Fainting spells or seizures |
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Desmayos y sudores ó ataques |
| I. Diabetes |
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Diabetes |
| 1. Do you urinate (pass water) more than 6 times a day |
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Orina usted mas de seis veces al dia |
| 2. Are you thirsty much of the time |
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Tiene sed la mayoría del tiempo |
| 3. Does your mouth frequently become dry |
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Se le reseca la boca frecuemente |
| J. Hepatitis, jaundice or liver disease |
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Malestar bilioso, hepatitis o enfermedad del higado |
| K. Arthritis |
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Artritis |
| L. Inflammatory rheumatism (painful, swollen joints) |
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Inflamación reumatica |
| M. Stomach ulcers |
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Ulceras estomacales |
| N. Kidney trouble |
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Efermedad del riñon |
| O. Tuberculosis |
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Tuberculosis |
| P. Do you have a persistent cough or cough up blood |
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Tos persistente o tose sangre |
| Q. Low blood pressure |
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Baja presion sanguinea |
| R. Venereal disease |
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Enfermedades venereas |
| S. Do you have a prosthetic
Hip/cadera
joint prosthesis / coyuntura prostetica
implants / implantes
bone plates / placa de hueso
or screws / tornillos
other / Si es asi, explique
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| 9. Have you had abnormal bleeding associated with previous extractions, surgery, or trauma |
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Ha sangradoanormalmente, cuando se le realiza una extraccion dental, cirujia o trauma |
| A. Do you bruise easily |
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Se moretea supiel facilmente |
| B. Have you ever required a blood transfusion |
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Ha requerido transfusion sanguinea |
| If so, explain the circumstances / Si contesta afirmativamente, explique |
| Do you have any blood disorder such as anemia |
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Tiene algun desorden sanquineo tal como anemia |
| 11. Have you had surgery or x-ray treatment for a tumor, growth, or other condition of your mouth or lips |
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Ha tenido cirujia o rayos C para tratar algun tumor crecimiento o otra enfermedad bucal o labial |
| 12. Are you taking any of the following / Esta tomando alguno de los siguientes medicamentos |
| If yes, indicate which |
| A. Antibiotics or sulfa drugs / Sulfas o antibioticos
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| B. Anticoagulants (blood thinners) / Anticoagulantes (adelgazador sanguineo)
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| C. Medicine for high blood pressure
/ Medicamento para la presion alta
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| D. Cortisone (steroids) / Cortisona (esteroides)
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| E.
Tranquilizers / Tranquilizantes
Antihistamine / Antihistaminico
Aspirin / Aspirina |
| F.
Insulin, tolbutamide (orinase) or similar drug / Insulina, tobultamida (orinase) o drogas similares |
| G. Digitalis or drugs for
/ Digitales o medicamentos para enfermedades
heart trouble / cardiacas
Nitroglyceri / Nitroglicerina |
| H.
Oral contraceptive or other hormonal therapy / Anticonceptivos orales o otra drogas similares |
| I.
Other drug or medicine / Otra droga o medicina |
| 13. Are you allergic or have you reacted adversely to any of the following / Es usted alerigico o ha reaccionado adversamente a los siguientes medicamentos: |
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Local anesthetics / Anestesia local |
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Penicillin or other antibiotics / Antibioticos o penicilina |
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Sulfa drugs / Drogas con sulfas |
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Barbiturates, sedatives or sleeping pills / Barbituricos, sedantes o pastillas para dormir |
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Aspirin
/ Apirina
Iodine / Yodo
Codeine or other narcotics / Codeina o otros narcoticos |
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Are you allergic to latex or rubber products / Es usted alergico al latex o productos de hule |
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Other allergies / Alguna otra
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| 14. Have you taken the diet medication Redux® (Fen-Phen)? |
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Ha tomado usted el medicamento Redux® (Fen-Phen) para su dieta |
| 15. Do you have any disease, condition, or problem not listed above that you think I should know about |
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Tiene usted alguna enfermedad condicion fisica o algun problema no enumerado anteriomente que usted crea que yo deba saber |
| 16. Are you employed in any situation which exposes you you regularly to x-rays or other ionizing radiation |
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Esta trabajando o esta en una situacion donde esta expuesto regularmente a Radiografias o alguna otra forma de radiacion |
| 17. Are you wearing contact lenses |
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Usa lentes de contacto |
| 18. Have you ever had any of the following conditions |
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Ha tenido alguna de las condiciones siguientes: |
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Herpes / Herpes
Hepatitis /
Hepatitis
Tuberculosis /
Tuberculosis
HIV / AIDS - HIV / SIDA |
| 19. Are you pregnant |
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Esta usted embarazada |
| 20. Do you have any problems associated with your menstrual period |
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Tiene algun problema asociado con su periodo menstrual |
| 21. Are you nursing |
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Esta dando pecho (amamantando) |
| 22. Have you had any serious trouble associated with any previous dental treatment / . Ha tenido problemas serios asociados con tratamiento dental |
| If so, explain / Si contesta afirmativamente, explique |
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| How often do you brush your teeth? / Que tan seguido se cepilla los dientes? |
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| When? / Cuando? |
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| 23. Do you use dental floss |
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Usa hilo dental |
| 24. Do your gums bleed or hurt? |
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Le sangran o le duelen sus encias |
| 25. Are any of your teeth sensitive to:
Hot / Caliente
Cold
/ Frio
Sweets / Dulce
Pressure / Presion |
| 26. Does food get caught in your teeth? |
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Retiene comida en sus dientes |
| 27. Do you clench or grind your teeth? |
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Aprieta o rechina sus dientes |
| 28.
Do you have frequent
headaches / Tiene dolores de cabeza
neck aches / cuello
or shoulder aches? / O hombre frecuentemente? |
| 29. Do you clench or grind your teeth? |
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Aprieta o rechina sus dientes |
| 30. Have you experienced any pain or soreness in the muscles of your face or around your ear? |
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Ha tenido algun dolor en los musculos de la cara o alrededor de los oidos |
| 31. Does your jaw click or pop? |
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Suena o cruje su quijada |
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| FOLLOW UP to Medical History by DENTIST ONLY |
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