Medical questionnaire for adults

Do you have questions about completing the form? Call us on (020) 673 81 14.

1Personal data

2Dental questions

3Any wishes

4Medical history

5Current situation and medication

6Conditions and shipping

Name(Required)

First Last

E-mail address(Required)

Telephone(Required)

Your gender

Date of birth(Required)

BSN Number

Health insurance policy number

Does periodontitis (chronically inflamed gums) run in your family?(Required)

Have you had cavities in the past 5 years?(Required)

Are teeth or molars sensitive when eating or drinking or brushing your teeth?(Required)

Do you have a place where food often gets stuck in your teeth?(Required)

Do you ever suffer from jaw snapping, clenching or grinding?(Required)

Has the position or shape of your teeth changed in the past 5 years?(Required)

Do you have little saliva or difficulty swallowing food?(Required)

Is there something about your teeth or smile that you would like to change?(Required)

What would you like to change?

Are there other things we can take into account?(Required)

What can we take into account?

Have you ever had a heart attack?(Required)

Have you ever had a brain hemorrhage (or TIA)?(Required)

Do you suffer from palpitations?(Required)

Are you being treated for high blood pressure?(Required)

Do you have chest pain on exertion/emotions?(Required)

Do you get short of breath when you lie flat in bed?(Required)

Do you have a heart valve defect, artificial heart valve or artificial hip?(Required)

Do you have a congenital heart defect?(Required)

Do you have a pacemaker (ICD) or neurostimulator?(Required)

Have you ever fainted at a dentist or doctor's office?(Required)

Do you suffer from epilepsy?(Required)

Do you suffer from hyperventilation?(Required)

Do you have lung complaints?(Required)

Do you have diabetes?(Required)

Do you have anemia?(Required)

Have you ever had prolonged bleeding after surgery?(Required)

Do you have hepatitis, jaundice or any other liver disease?(Required)

Do you have kidney disease?(Required)

Do you have rheumatism and/or chronic joint complaints?(Required)

Have you been irradiated because of a tumor in the head and neck area?(Required)

Are you checked by the Thrombosis Service?(Required)

Are you being treated by a doctor or medical specialist?(Required)

With which doctor/medical specialist are you being treated and for which complaint?

Are you allergic to something?(Required)

What are you allergic to?

Have you ever had a serious illness?(Required)

Do you smoke?(Required)

How many cigarettes do you smoke on average per day?

Please enter a number from 1 to 100.

Do you drink alcohol?(Required)

How many glasses do you drink on average per week?

Please enter a number from 1 to 100.

Do you suffer from depression or depression?(Required)

Do you have a disease or condition that was not asked about?(Required)

Can you explain this?

Do you currently have an infectious disease?(Required)

Do you use blood thinners?(Required)

Do you use medication?(Required)

An overview of your medication(Required)

Indicate which medication you use, how often you use this medication and in what quantities

Are you pregnant?(Required)

Are you breastfeeding?(Required)

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Medical questionnaire for adults

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Due to our holiday, the practice is closed from Friday 14 June to Friday 28 June.