DENTALBRERACLINIC • Medical history sheet

Please complete this form as accurately as possible. It will remain for the exclusive use of the Firm.
To ensure proper provision of our professional services, you must provide the requested information.
If you are a minor or a person under legal guardianship, please enter their information and have a parent or guardian sign it.

Are you currently being treated for any medical condition?
Have you had any serious illnesses or undergone any surgical procedures in the past 5 years?
Do you currently have, or have you ever had, any of the following diseases and/or conditions?
Cardiovascular diseases
Other diseases
Do you have any of the following:
Skin diseases
Other diseases
Digestive system diseases
Other diseases
Metabolic diseases
Other diseases
Blood disorders
Other diseases
Liver diseases
Other diseases
Neurological conditions
Other diseases
Pulmonary or respiratory diseases
Other diseases
Rheumatic diseases
Other diseases
Sexually transmitted diseases
Other diseases
Have you ever experienced rapid weight changes (more than 4 kg)?
Are you currently undergoing, or have you previously undergone, chemotherapy or radiation therapy?
Do you experience excessive bleeding during extractions, surgeries, etc.?
Are you taking or have you taken any of the following medications in the last 5 years?
Caselle di Spunta
Other medications
Are you allergic to, or have you ever had an abnormal reaction to:
Caselle di Spunta
Other medications
Do you smoke?
Do you abuse alcohol or have you used - or do you currently use narcotics?
Have you ever had problems with anesthesia?
Have you ever experienced vertigo?
Have you ever experienced a sensation of instability while standing still or walking?
Do you wear contact lenses?
Do you have any other diseases, conditions, or problems that are not listed?
Are you pregnant?
Are you breastfeeding?
Do you take oral contraceptives?
Does he or she have phonatory problems or speech sound disorders?
Do you breathe through your mouth, or only partially?