Medical Record - Dental Surgery


    Please fill out the form completely and truthfully in its entirety.
    The data collected are essential for proper medical evaluation and for your safety during dental procedures.

    PERSONAL DATA.






    Gender


    Medical history

    Heart disease (hypertension, arrhythmias, heart attack)?

    Respiratory diseases (asthma, bronchitis)?

    Diabetes?

    Epilessia?

    Liver disease (hepatitis)?

    Kidney disease?

    Thyroid problems?

    Malattie autoimmune (lupus, arthritis rheumatoid)?

    HIV/AIDS?

    Tuberculosis?

    Tumors or cancer treatments?

    Terapie biologiche, chemioterapia o radioterapia?

    Osteoporosis?

    Allergy

    Are you allergic to drugs or materials (e.g., antibiotics, anesthetics, latex)?


    Medications currently taken

    Do you take medication regularly?

    Anticoagulanti (es. aspirina, warfarin)?

    Corticosteroids or immunosuppressants?

    Surgery and anesthesia

    Have you had surgery in the past?

    Did you have any problems with anesthesia?

    Hemorrhages

    Bleed easily?

    Are there any cases in the family with coagulation disorders?

    Women - Pregnancy / Breastfeeding

    Are you pregnant?

    Are you breastfeeding?

    Vaccinations

    È vaccinato contro l’epatite B?

    Habits and substances

    Do you smoke?


    Do you consume alcohol?



    Dental experiences

    Have you ever had any adverse reactions during dental treatments?


    Statement and signature

    I declare that the above information is true and complete.

    I consent to the processing of personal data in accordance with current regulations.