Historia Clinica Odontoldgica
Fecha: J
Nombre y Apellido: Edad: _________ Masculino_) Femenino
Ce Direccién:
Lugar de nacimiento:. Fecha de nacimiento: / / /
a
Antecedentes familiares:
Motive de consulta: Dolor: Control:
‘Sangramiento en las encias: Restauracion protésica: Otro indique cual:
Enfermedad actual:
Si | No Si | No
GEsté usted bajo tratamiento médico? Sufre o ha sufrido de:
Toma actualmente algiin medicamento? ~ Enfermedades venéreas
¢lehan practicado alguna intervencién quirirgica? = Problemas del orazén
¢Haecibido alguna transfusién sanguinea? “Hepatitis
¢Ha consumido o consume drogas? =Fiebre reumdtica
Ha presentado reaccién alérgica a: “Asma
~Penicilina ~Didbetes
~Anestesia - Uleera gastrica
~Aspirina, yodo, “Tiroides
merthiolate, otros: {Ha tenido limitacion al abrir o cerrarla boca?
‘Sufre de tensién arterial: {Siente ruidos en la mandibula al abrir o cerrar la boca?
“Alta
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