Adult health questionnaire

1Personal data

2Dental questions

3Any wishes

4Medical history

5Current situation and medication

6Terms 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 periodontal disease (chronically inflamed gums) run in your family?(Required)

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

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

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

Do you ever suffer from jaw popping, 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 anything 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 cerebral hemorrhage (or TIA)?(Required)

Do you suffer from palpitations?(Required)

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

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

Do you become 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 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 a procedure?(Required)

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

Do you have kidney disease?(Required)

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

Have you had radiation treatment for a tumor in the head/neck area?(Required)

Are you being checked by the thrombosis service?(Required)

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

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

Are you allergic to anything?(Required)

What are you allergic to?

Have you ever suffered 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 an illness or condition that has not been asked about?(Required)

Can you explain this?

Do you currently have a contagious disease?(Required)

Are you taking blood thinners?(Required)

Are you taking 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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Adult health questionnaire

New patients
are very welcome

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Adult health questionnaire

New patients are very welcome

New patients
are very welcome