mEDICAL hISTORY fORM. Please complete the following form (Complete el siguiente formulario). Pacient´s Name BirthDate PhoneNo Email Nacionality Address This questionnaire is the equivalent of an "Affidavit (Este cuestionario tiene el tenor de una “Declaración Jurada”) Living Father (Padre con vida) SI NO Current or past illness Living Mother (Madre con vida?) SI NO Current or past illness Siblings (Hermanos?) SI NO Healthy? Any current illness? (Sufre de alguna enfermedad) SI NO What type of illness? Currently attending or receiving tratment? (Hace algún tratamiento médico) SI NO What Kind of treatment What type of drugs or medication do you normally take Do you practice any sports (Realiza algún deporte?) SI NO Do you notice any kind of discomfort when doing it? (Nota algún malestar al realizarlo?) SI NO Are you allergic to any type of drug or medication (Es alérgico a algún medicamento?) SI NO When your tooth is removed or injured, do you heal well? Do you bleed a lot? Do you have a collagen problem (joint pain)? History of rheumatic fever? (Antecedentes de fiebre reumática?) SI NO Do you take care of yourself with any type of medication? Are you diabetic? (Es diabético?) SI NO Is your diabetes under control? What control it? Do you have any type of heart problem? (Tiene algún problema cardiaco?) SI NO what kind of problem? Send
