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* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Medical History Name:________________________________________ Birthdate:________________________________ 1. What is your BC Care Card or personal health number? ____________________________________ 2. Who is your family physician? _________________________________________________________ 3. Do you have any major medical issues we should be aware of? Yes No __________________________________________________________________________________ __________________________________________________________________________________ 4. Have you been hospitalized for an overnight stay in the past 5 yrs? Yes No (if yes what for) __________________________________________________________________________________ 5. Have you been under the care of a medical doctor for a specific condition in the past 2 years? Yes No (if yes what for) _____________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ 6. Have you ever had a problem with excessive bleeding following medical or dental surgery? Yes No __________________________________________________________________________________ __________________________________________________________________________________ 7. Do you regularly take any prescription medications of any kind? Medication Prescribed _______________________ _______________________ _______________________ Yes No (please list all) Reason for Taking ________________________________________________________ ________________________________________________________ ________________________________________________________ 8. Do you get shortness of breath when you lie down? Yes No 9. Are you allergic to Latex? Yes No 10. Do you have any allergies/sensitivities to medications or drug of any kind? _____________________ __________________________________________________________________________________ 11. Do you have an artificial heart valve or a joint replacement like a hip or knee? Yes No (if yes what was the surgery date) ______________________________________________________ 12. Have you been advised to take antibiotic pre-medication before every dental visit? Yes No (if yes for what reason) __________________________________________________________________________ 13. Are you taking, or have you ever taken bisphosphonate medication such as Actonel, Fosamax or Zometa? Yes No (if yes for how long) _________________________________________________ WOMEN 14. Are you or might you be pregnant or nursing? Yes No 15. Are you taking birth control medication? Yes No 16. Are you anticipation pregnancy in the next 3 months? Yes No Do you have a history of heart trouble? (Circle any that apply) Angina Pectoris Congenital Heart Lesions Low Blood Pressure Mitral Valve Prolapse-Regurgitation Heart Attack Heart Disease Heart Failure Heart Pacemaker Heart Surgery Heart Valve Problems High Blood Pressure Heart Murmur General History (circle all that apply) Anemia Arthritis Asthma Bruise/Swell Easily Cancer Treatment Crohn's /Colitis Diabetes Type I or II Epilepsy/Seizures Hemophilia Hepatitis A, B or C Aids or HIV Thyroid Problems Kidney Disease Liver Disease Osteoporosis Rheumatic Fever Sinusitis Tuberculosis Ulcer Signature of patient/guardian:____________________________________ Date:______________________