DENTAL and HEALTH QUESTIONNAIRE




    Is there any special problem with your teeth that brought you in today?
    (Hay algun problema con sus dientes hoy?)
    Yes/SiNo
    Are you having any discomfort at this time?
    (Tiene problems con su dientes? Dolor?)
    Yes/SiNo

    Please explain/Explique

    Are you sensitive to:
    (Usted es sensible a:)
    Cold(Frio)Hot(Caliente)Sweets(Dulces)Chewing(Masticar)
    When was your last dental exam?
    (Cuando fué la ultima vez que tuvo un examen dental?)
    When did you last have dental X-rays?
    (Cuando fué la ultima de rayos X de su dientes?)
    When was your last dental cleaning?
    (Cuando fué la ultima vez que le limpiaron los dientes?)

    Do you use a fluoridated toothpaste?
    (Utiliza una pasta de dientes fluorada?)
    Yes/SiNo
    When do you brush your teeth?
    (Cuándo te cepillas los dientes?
    Morning(Mañana)After Meals(después de las comidas)Night/(Noche)
    When do you floss your teeth?
    (Cuándo usa hilo dental?)
    Never/(Nunca)When food is stuck between teeth/(Cuando la comida está pegada)1x/day(1x/día)1-4x/week/(1-4x/semana)After Meals/(Después de comer)
    What type of water do you drink?(¿Qué tipo de agua bebes)
    (Qué tipo de agua tomas?)
    Tap or Filtered Water/(Grifo o agua filtrada)Unfluoridated Bottled Water/(agua embotellada sin fluor)
    Do you drink soda, juice, sports or energy drink most days of the week?
    (Bebes refresco, jugo, deportes o bebida energética la mayoría de los días de la semana?)
    Yes/SiNo

    Do you have any of the following? (Ha tenido usted?)

    Bleeding Gums/Sangrando de la encia?
    Yes/SiNo
    Bad Breath/Mal aliento?
    Yes/SiNo
    Clicking jaw/Ruido en la quijada
    Yes/SiNo
    Grinding teeth at night/Rechina los dientes en la noche
    Yes/SiNo

    Do you smoke or chew tobacco?
    (¿Fuma o mastica tabaco?)
    Yes/SiNo
    If yes, how many cigarettes/day?
    (Si la respuesta es sí, cuántos al día?)
    Former tobacco user?
    (Ex consumidor de tabaco)
    Yes/SiNo
    Year you quit using tobacco?
    (Año en que dejó de usar tabaco?)
    Are you pregnant?(Esta usted embarazada?)
    Yes/SiNo
    Do you take any over the counter medicines, prescription medicines, vitamins, supplements,
    or home remedies?
    (Toma alguna medicina sin receta, medicamentos recetados, vitaminas, suplementos o remedios caseros?)
    Yes/SiNo

    Please list (Escribalas)

    Are you allergic to any medications? (Esta usted alergico a medicinas?)

    Penicillin/Penicilina
    Yes/SiNo
    Aspirin/Aspirina
    Yes/SiNo
    Ibuprofen/Naproxen
    Yes/SiNo
    Codeine/Codeina
    Yes/SiNo
    Sulfa drugs
    Yes/SiNo

    List Others/Lista las otras

    Have you ever had?(Ha tenido usted?)

    Congenital heart valve defect/Defecto congénito de la válvula del corazón
    Yes/SiNo
    Previous Bacterial Endocarditis/ Infeccion en el corazon
    Yes/SiNo
    Heart valve replacement/Pacemaker/Remplazo de valvula del corazon/marcapaso
    Yes/SiNo
    Heart Surgery/Cirugia del corazon
    Yes/SiNo
    Heart disease/Problemas de corazon
    Yes/SiNo
    Joint replacement/Suplantamiento
    Yes/SiNo
    Stroke/Embolia
    Yes/SiNo
    High blood pressure/Presión arterial alta
    Yes/SiNo
    Diabetes
    Yes/SiNo
    Diabetes in your family/Diabetes en su familia
    Yes/SiNo
    Mental illness/Enfermedad mental
    Yes/SiNo
    Depression/Depresión
    Yes/SiNo
    Anxiety/Ansiedad
    Yes/SiNo
    Bipolar/Bipolar
    Yes/SiNo
    Schizophrenia/Esquizofrenia
    Yes/SiNo
    Fainting/Desmayo
    Yes/SiNo
    Dizziness/Mareo
    Yes/SiNo
    Cancer
    Yes/SiNo
    Radiation therapy/Terapia de radiacion
    Yes/SiNo
    Tuberculosis
    Yes/SiNo
    Jaundice/ Ictericia
    Yes/SiNo
    Hepatitis
    Yes/SiNo
    Liver disease/Enfermedad de Higado
    Yes/SiNo
    Kidney disease/Enfermedad de Rinones
    Yes/SiNo
    Sinus trouble/Problemas de sinusitis
    Yes/SiNo
    Asthma/Asma
    Yes/SiNo
    Bleeding disorder/Desorden de hemorragia
    Yes/SiNo
    Venereal disease/ Enfermedad venerea
    Yes/SiNo
    AIDS/HIV SIDA/HIV
    Yes/SiNo
    Epilepsy/convulsions/Epilepsea/convulsion
    Yes/SiNo
    Thyroid problems/Problemas de su tiroides
    Yes/SiNo
    Osteoporosis
    Yes/SiNo
    Other problems/Otros problemas
    Yes/SiNo

    Explain/Explique

    I authorize diagnostic procedures including but not limited to x-rays and dental treatment. It is my responsibility to inform Saban Community Clinic of any changes in my health and medication. Please email this completed form to send form to dentalpatients@sabancommunityclinic.org.

    Doy mi permiso para radiografias y tratamiento dental. Es mi responsabilidad de informarle a Saban Comnunity Clinic de cualquier cambio en mi salud y medicina. Por favor envíe esta forma completada por correo electrónico a dentalpatients@sabancommunityclinic.org.

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