pittsburghdentist.com€¦ · food (speci5') hay fever/seasonal animals other yes no are you...

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Page 1: pittsburghdentist.com€¦ · Food (speci5') Hay fever/seasonal Animals Other YES NO Are you Pregnant? Do you use tobacco? (smoking, snuff, chew) Do you drink alcoholic beverages?
Page 2: pittsburghdentist.com€¦ · Food (speci5') Hay fever/seasonal Animals Other YES NO Are you Pregnant? Do you use tobacco? (smoking, snuff, chew) Do you drink alcoholic beverages?
Page 3: pittsburghdentist.com€¦ · Food (speci5') Hay fever/seasonal Animals Other YES NO Are you Pregnant? Do you use tobacco? (smoking, snuff, chew) Do you drink alcoholic beverages?
Page 4: pittsburghdentist.com€¦ · Food (speci5') Hay fever/seasonal Animals Other YES NO Are you Pregnant? Do you use tobacco? (smoking, snuff, chew) Do you drink alcoholic beverages?