DENTALBRERACLINIC • Periodic Anamnesis SheetPlease enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Surname and Name (maiden name)Residence addressDo Are If CapCityStateAre you being treated for any illness?YesNo(Malattie dell'apparato cardio-vascolare, della pelle, dell'apparato digerente, metaboliche, del sangue, epatiche, neoplastiche, neurologiche, polmonari o respiratorie, reumatiche, congenite, immunologiche, renali/urogenitali, oncologiche)If so, which one?Have you had any serious illnesses or surgeries?YesNoIf so, which one?Do you take any medications?YesNoIf so, which one?Do you have allergies?YesNoIf so, to what?You smoke?YesNoIf so, how much?For female patients only:Are you pregnant?YesNoAre you breastfeeding?YesNoDate *Send
