Intake (en)

Naam

Date of birth

Street and no.

Postal code and city name

Phone number

E-mailadres ^*

Social security number

When was your last visit to the dentist?

Were any treatments done?

YesNo

What treatments were done then?

Do you currently have problems with your teeth?

YesNo

What problems do you currently have with your teeth?

Have you ever had orthodontic treatment (braces)?

YesNo

Are you nervous when you have to go to the dentist?

YesNo

Are you satisfied with your teeth?

YesNo

What would you like to have changed?

Do you ever have pain or a constricted feeling to the chest when you're exercising (angina pectoris)?

YesNo

Have you gotten angina pectoris again, despite a bypass surgery, a Dotter procedure or laser therapy?

YesNo

Do you have complaints when in rest?

YesNo

Have the complaints increased lately?

YesNo

Have you needed to cut back on your activities?

YesNo

Have you ever had a heart attack?

YesNo

Have there been complications afterwards?

YesNo

Are you still having complaints?

YesNo

Have you had a heart attack in the past 6 months?

YesNo

Do you have a heart murmur, a heart valve defect?

YesNo

Have you had vascular surgery in the past 6 months?

YesNo

Do you need antibiotics with dental treatment?

YesNo

Do you have complaints due to a heart valve defect?

YesNo

Do you have an artificial hip or an artificial heart valve?

YesNo

Do you ever have heart palpitations, without exerting yourself?

YesNo

Do you need to rest, sit or lie down when the palpitations happen?

YesNo

Do you get pale, dizzy or short of breath during the palpitations?

YesNo

Do you have heart weakness?

YesNo

Are your feet swollen in the evening?

YesNo

Do you have to urinate more than twice at night?

YesNo

Are you sleeping with more than 2 pillows, because you’ll get short of breath otherwise?

YesNo

Do you wake up short of breath at night?

YesNo

Do you have high blood pressure?

YesNo

Is your systolic blood pressure usually between 160 and 200?

YesNo

Is your diastolic blood pressure usually between 95 and 115?

YesNo

Is your systolic blood pressure usually 200 or higher?

YesNo

Is your diastolic blood pressure usually 115 or higher?

YesNo

Have you had paralyses (stroke or attaque) or speech disorders?

YesNo

Have you had similar complaints the past 24 hours?

YesNo

Have you had a stroke or attaque in the past 6 months?

YesNo

Have you ever fainted during a dental or medical procedure?

YesNo

Do you use medication for epilepsy?

YesNo

Do you switch medication regularly?

YesNo

Do you have episodes despite your medication?

YesNo

Do you ever suffer from hyperventilation?

YesNo

Do you have asthma?

YesNo

Does this affect you at this moment?

YesNo

Do you have fever episodes?

YesNo

Do you have bad lungs?

YesNo

Do you cough up more than a cup of phlegm a day?

YesNo

Are you short of breath when climbing stairs after 20 steps?

YesNo

Are you short of breath when getting dressed?

YesNo

Do you have hay fever?

YesNo

Have you ever had an allergic reaction to the use of medicines or the use of medical materials (iodine, rubber, band aids)?

YesNo

Do you use medicine for your allergies?

YesNo

Has the allergy occurred when visiting the dentist?

YesNo

Has the allergy occurred during local anesthetics?

YesNo

Are you allergic?

YesNo

What are you allergic for?

Are you allergic to penicillin or antibiotics?

YesNo

Which penicillin or antibiotics are you allergic for?

Do you have diabetes?

YesNo

Do you use insulin?

YesNo

Are you often in misbalance (hypoglycemia/hyperglycemia)?

YesNo

Are you being treated for complications of heart and vessels due to your diabetes?

YesNo

Have you been diagnosed with enhanced thyroid function?

YesNo

Are you being treated or under control for this?

YesNo

Do you have complaints despite treatment?

YesNo

Have you been diagnosed with slow thyroid function?

YesNo

Are you being treated or under control for this?

YesNo

Do you have complaints despite treatment?

YesNo

Do you have a liver disease?

YesNo

Have you had this for longer than 6 months?

YesNo

Are you on a special diet or are you using medicine for this?

YesNo

Do you have a chronic kidney illness for which you are on a diet?

YesNo

Are you receiving renal function-replacement treatment?

YesNo

Do you have chronic gastrointestinal complaints, because of which you lost more than 5kg in weight?

YesNo

Have you had diarrhea for more than 6 months?

YesNo

Do you have a contagious disease at the moment?

YesNo

Which contagious disease do you have?

Do you have anemia with complaints (tired, dizziness)?

YesNo

Do you have a malignant disease of the lymph nodes or a blood disease?

YesNo

Which disease do you have?

Are you being treated for this?

YesNo

Do you have fever episodes?

YesNo

Have you been diagnosed with bleeding tendency?

YesNo

Do you bleed longer than 1 hour after an injury or procedure?

YesNo

Do you get bruises without bumps or punches?

YesNo

Have you had radiation therapy for a tumor or growth in your head neck area?

YesNo

Was this less than 5 years ago?

YesNo

Are you currently using medication?

YesNo

Which medication?

For your heartFor high blood pressureAspirin or painkillers (for joint complaints)For diabetesPrednisone, corticosteroids or other defense inhibitorsMedicine for cancer or bleeding diseasePenicillin or antibioticsSedatives, sleeping pills, antidepressants

Other medication

Are you under control of the thrombosis service?

YesNo

Do you use drugs on a daily basis?

YesNo

Do you use more than 5 alcoholic beverages a day?

YesNo

Do you smoke?

YesNo

How many a day?

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Intake

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