Request edit access
Anamnestic survey questionnaires
The following questions are intended to allow a better understanding of your overall health, thus avoiding
promptly with surgery or pharmacological treatments that are contraindicated for you.
The answers are to be considered strictly confidential and related to professional secrecy.
Dott. Alessio Bosco, 2018
Sign in to Google to save your progress. Learn more
First Name *
Family Name *
Address *
City and Zip Code *
Born In *
Born the *
Fiscal Code *
Actual or past Job
Tel. (mobile) *
How did you hear about us? *
Captionless Image
Are you in good health? *
Have you ever received any local anesthetics? *
Are you a heavy smoker? (+ 10 per day) *
Do you take any type of regular medication? *
If yes, please specify which
Do you suffer from allergies? *
Have you ever had an allergic reaction to drugs such as Penicillin or Aspirin? *
Have you ever had Viral Hepatitis? *
Subjects HCV HIV - positive privately agree with the doctor healing modalities in order to better protect their own health and third parties. Under no circumstances will be discriminated against at the Studio. High standards techniques of sterilization are used for everyone for your safety.
Do you suffer from Diabetes? *
Have you ever had Heart Problems? *
Have you ever had Lung Problems? *
Have you ever had any problems with the clotting blood? (Bleeding? Thrombosis?) *
Do you have Kidney Problems? *
Have you ever taken medication for osteoporosis? *
(for women) and are you Pregnant?
Clear selection
If you believe you have a health problem not mentioned above that the doctor should know them, please briefly summarize
Please check all that matters *
Required
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy

Does this form look suspicious? Report

Google Forms