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Medical history

Medical History

You will be asked to complete a medical history list before your first appointment. This is important because many physical illnesses and medicines can influence the prevention of problems with your teeth and the performance of long-term work. If we are aware of your medical situation, we can take the appropriate precautions. It is important that you also inform us of any future changes in your medical situation.

Naam

Name

Date of birth

E-mail

Gender

Male Female Non-binary

Today's date

Do you have any allergies?

Yes No

Have you ever had a heart attack?

Yes No

If so, when?

Do you suffer from palpitations?

Yes No

Are you being treated for high blood pressure?

Yes No

What is your blood pressure?

Do you feel any pain on the chest while exercising?

Yes No

Do you get shortage of breath while lying flat on your bed?

Yes No

Do you have a heart valve deficiency or an artificial heart valve?

Yes No

Do you have a congenital heart defect?

Yes No

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

Yes No

Have you ever fainted during a dental or medical treatment?

Yes No

Do you have epilepsy or a falling disease?

Yes No

Have you ever had a brain haemorrhage, stroke or TIA?

Yes No

Do you suffer from lung complaints such as asthma, bronchitis or chronic cough?

Yes No

Do you suffer from diabetes?

Yes No

Do you suffer from anemia?

Yes No

Do you use something for this?

Have you ever had prolonged bleeding after tooth extraction?

Yes No

Do you have or have had hepatitis, jaundice or other liver diseases?

Yes No

Do you have any kidney diseases?

Yes No

Do you have rheumatism and/or chronic joint complaints?

Yes No

Have you ever had a irradiation for a tumor in your head or neck?

Yes No

Do you smoke?

Yes No

If so, how many a day?

Do you drink alcohol?

Yes No

For the women: are you pregnant?

Yes No

Do you use any medication?

Yes No

If so, what kind of medication do you use?

Do you have a disease or condition that has not been asked about?

Yes No

If so, which?

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Adres:

Tandartsenpraktijk de Nieuwegracht
Nieuwegracht 79
3512LH , Utrecht

Contact:

Telefoon: 030 - 2313130
info@tandartsenpraktijkdenieuwegracht.nl

Contact

Tandartsenpraktijk de Nieuwegracht
Nieuwegracht 79
3512LH , Utrecht
Telefoon: 030 - 2313130
E-mail: info@tandartsenpraktijkdenieuwegracht.nl

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Openingstijden

maandag08:00 - 17:00
dinsdag08:00 - 17:00
woensdag08:00 - 17:00
donderdag08:00 - 17:00
vrijdag08:00 - 17:00
zaterdagGesloten
zondagGesloten

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