030 - 231 03 20

info@dentalcaremaliebaan.nl

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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.

N.B.: only fill out this form at request of the dental practice.

My Website

Name

Date of birth

E-mail

Gender

Male Female Non-binary

Today's date

Do you have any allergies?

Yes No

If so, for what?

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 and/or emotions?

Yes No

Do you have swollen ankles/feet?

Yes No

Are you short of breath during exercises?

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, neurostimulator or ICD?

Yes No

Are you currently being monitored by the thrombosis services?

Yes No

Have you ever fainted during a dental or medical treatment?

Yes No

Do you suffer from hyperventilation?

Yes No

Do you have epilepsy/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

If so, are you short of breath?

Yes No

Do you suffer from diabetes?

Yes No

If so, do you use insulin?

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 hepatitis, yellow fever or any other liver disease?

Yes No

Do you have chronic stomach complaints?

Yes No

Do you have a kidney disease?

Yes No

Do you suffer from a thyroid disorder?

Yes No

Do you have rheumatism and/or chronic joint complaints?

Yes No

Do you have an artificial joint or joint replacement?

Yes No

Have you ever used in the past medication for osteoporosis such as denosumab or bisphosphonate?

Yes No

If so, please specify

Do you have a contagious disease?

Yes No

If so, please specify

Have you ever received radio therapy for a tumour in head and/or neck?

Yes No

Do you smoke and/or use an e-smoker/vape?

Yes No

If so, how many a day?

Do you use drugs?

Yes No

If so, what drugs do you use?

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?

I have read and agree to the privacy policy.

Dental Care Maliebaan

Openingstijden:

maandag
08:30 - 17:00
dinsdag
08:30 - 17:00
woensdag
08:30 - 17:00
donderdag
08:30 - 17:00
vrijdag
08:30 - 17:00
zaterdag
Gesloten
zondag
Gesloten

Extra berichtgeving openingstijden

Adres:

Dental Care Maliebaan
Maliebaan 63
3581 CE Utrecht

Contact:

Telefoon: 030 - 231 03 20
info@dentalcaremaliebaan.nl

Contact

Dental Care Maliebaan
Maliebaan 63
3581 CE Utrecht
Telefoon: 030 - 231 03 20
E-mail: info@dentalcaremaliebaan.nl

Openingstijden

maandag08:30 - 17:00
dinsdag08:30 - 17:00
woensdag08:30 - 17:00
donderdag08:30 - 17:00
vrijdag08:30 - 17:00
zaterdagGesloten
zondagGesloten

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