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HISTORIA CLÌNICA EN INGLÈS

Trabajos: HISTORIA CLÌNICA EN INGLÈS
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Enviado por:  BeereSalazar  17 diciembre 2012
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CLINICAL HISTORY

Name: Age:

Address: Phone:

Occupation: Place of Birth:

E-mail address:

• MEDICAL HISTORY

Reason for consultation

Do you suffer from any illness? (if so, which one)

Are you taking any medication? (which?)

Are you allergic to any medication, food or other? (specify which)

Have you received any surgery or traumatism? (specify which and when)

Have you received a blood transfusion? (specify when)

Blood type

WOMEN< are you experiencing any of the following at the present time?

YES NO

Menstruation

Pregnancy

Breast feeding

Menopause

Weight

T/A

Pulse

Time of bride

Has any family member or partner had (or has at the present time) the following illnesses?

YES NO YES NO

Diabetes HIV/AIDS

Cancer Heart disease

Obesity Convulsions

Arterial Hypertension Depresision

Asthma Rheutmatoid Arthritis

Congenital Malformation

 Observations

 Laboratory Studies

Date of last dental visit?

What was the reason for the consultation?

Have you been administered local or general anesthetic? Yes No

Did you experience any unfavorable reactions to this? Yes No

Have there been any negative experiences with previous dental visits? Yes No

For what reason?

Have you suffered trauma to the mouth, teeth or head? Yes No

When and how?

Explain

Do you have any of the following habits?

Breathing through the mouth Grinding teeth Biting nails

Biting or chewing lips xxxxxxxxxxxxxxxxxxx Other

Do you brush your teeth daily? Yes No

How often?

Do you use dental floss? Yes No

Do you use mouth wash? Yes No

 Observations

...



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