Past Medical History

Name/Nombre

Date of Birth/Fecha de Nacimiento

PAST MEDICAL HISTORY I HISTORIA MEDICA

(If you personally have EVER HAD or CURRENTLY HAVE any of the problems listed below, please circle YES and give details in the comments section. Otherwise, please circle NO)

(Por favor conteste todas las preguntas que siguen. Si su respuesta es "SI”, de una explicacion abajo)

HEALTH CONDITION

1. DIABETES / DIABETES

Yes / Si No

2. HIGH BLOOD PRESSURE / ALTA PRESION

Yes / Si No

3. HEART DISEASE OR PROBLEMS, RHEUMATIC FEVER, RHEUMATIC HEART DISEASE or MITRAL VALVE PROLAPSE. If yes, do you require antibiotics for dental procedures? CUALQUIER ENFERMEDAD o PROBLEMA DEL CORAZON Encaso que si, requiere antibioticos para trabajo dental?

Yes / Si No

4. IMMUNE SYSTEM DISORDER (ie, lupus, rheumatoid arthritis) DESORDEN DEL SYSTEMA INMUNE (lupus, artritis reumatoide)

Yes / Si No

5. BLADDER INFECTIONS or KIDNEY PROBLEMS (ie, stones, infection) INFECCIONES DE LA VEJIGA o PROBLEMAS DEL RINON

Yes / Si No

6. SEIZURE DISORDER (epilepsy) or NEUROLOGIC PROBLEMS PROBLEMAS NEUROLOGICOS o DESORDEN EPILEPTICO

Yes / Si No

7. MENTAL HEALTH DISORDERS or PROBLEMS / DESORDENES o PROBLENAS MENTALES

Yes / Si No

8. DEPRESSION or POSTPARTUM DEPRESSION / DEPRESION o DEPRESION POSPARTOS

Yes / Si No

9. LIVER DISEASE or HEPATITIS (yellow jaundice) / ENFERMEDAD DEL IGADO o HEPATITIS

Yes / Si No

10. VARICOSE VEINS, PHLEBITIS or EMBOLISM (blood clots inside the vein) VARICES, FLEBITIS o EMBOLIA

Yes / Si No

11. THYROID PROBLEMS / PROBLEMAS DE LA TIROIDEO

Yes / Si No

12. MAJOR TRAUMA or DOMESTIC VIOLENCE / TRAUMA MAYOR o VIOLENCIA DOMESTICA

Yes / Si No

13. HISTORY OF BLOOD TRANSFUSION / TRANSFUSION DE SANGRE

Yes / Si No

14. TOBACCO USE PAST or PRESENT / USO DE TABACCO PRESENTE o PASSADO

Yes / Si No

a. If yes, how many cigarettes smoked PER DAY now? Cuantos cigarros al dia?

b. If you quit smoking, when did you quit? / si dejo de fumar, cuando fue eso?

15. ALCOHOL USE I USO DE ALCOHOL

a. ALCOHOL USE CURRENTLY / PRESENTE

Yes / Si No

b. ALCOHOL USE BEFORE PREGNANCY / USO DE ALCOHOL ANTES DE EMBARAZO

Yes / Si No

16. ILLICIT DRUG USE / USO DE DROGAS

a. ILLICIT DRUG USE CURRENTLY / USO DE DROGAS ILICITAS PRESENTE

Yes / Si No

b. ILLICIT DRUG USE BEFORE PREGNANCY / USO DE DROGAS ANTES DE EMBARAZO

Yes / Si No

18. ASTHMA, TUBERCULOSIS or LUNG PROBLEMS / TUBERCULOSIS, o PROBLEMAS DE PULMONES

Yes / Si No

19. HAY FEVER or SEASONAL ALLERGIES / FIEBRE DEL HENO o ALERGIAS ESTACIONALES

Yes / Si No

20. ALLERGIES TO ANY MEDICATIONS / ALERGIAS A UN MEDICAMENTO

Yes / Si No

If yes, please specify

b. ALLERGIES TO LATEX I ALERGIAS A LATEX (GUANTES DE ULE)

Yes / Si No

21. BREAST IMPLANTS, BREAST SURGERY or ANY PROBLEMS IMPLANTES, CIRUJIA, o PROBLEMAS DE LOS SENOS

Yes / Si No

22. GYNECOLOGIC SURGERY (cervix, uterus, tubes, ovaries- DESCRIBE BELOW) This includes freezing of the cervix (CRYO), cone biopsy of the cervix or LEEP, ovarian or tubal surgery / CIRUJIA GINECOLOGICA (utero, ovarios, cervical)

Yes / Si No

23. ANY OTHER OPERATIONS or HOSPITALIZATIONS (DESCRIBE BELOW) / CUALQUIER OTRA OPERACION o HOSPITALIZACION

Yes / Si No

24. ANESTHESIA COMPLICATIONS / COMPLICACIONES DEVIDO A LA ANESTESIA

Yes / Si No

25. HISTORY OF ABNORMAL PAP SMEAR / PAPANICOLADO ABNORMAL

Yes / Si No

26. ABNORMAL UTERUS (fibroids, congenital problems, DES daughter) / UTERO ABNORMAL (problemas congenitales, tumor)

Yes / Si No

27. INFERTILITY or PROBLEMS GETTING PREGNANT / INFERTILIOAD

Yes / Si No

28. IN-VITRO FERTILIZATION / FERTILIZACION IN-VITRO

Yes / Si No

29. ANY TYPE OF CANCER or MALIGNANCY / ALGUN TIPO DE CANCER MALIGNO

Yes / Si No

30. EASY BLEEDING or BRUISING BEFORE PREGNANCY / SANGRA o SE MORENTONEA FACILMENTE

Yes / Si No

31. CHEMOTHERAPY or RADIATION TREATMENTS / QUIMIOTERAPIA o RADIACION

Yes / Si No

32. DIETARY RESTRICTIONS or FOOD INTOLERANCES / RESTRICCIONES DE DIETA

Yes / Si No

33. ANY CONDITION NOT MENTIONED IN THIS QUESTIONAIRRE (DESCRIBE BELOW) / ALGUNA CONDICION NO MENSIONADA

Yes / Si No

COMMENTS (please explain any YES answers above) / COMMENT ARIOS (Explique todas sus respuestas "Si")

Pregnancy History

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