Anamnese – De Amsterdamse Tandarts

De Amsterdamse Tandarts

1Personal

2Questions

3Signature

First name *

Last name *

Date of Birth *

E-mail address *

Mobile number *

Social number

Vragen

1.0 1. Do you experience any pain or pressure in your chest during mild effort (angina pectoris)? *

1.1 Did you have to reduce your activity level? *

1.2 Have above mentioned complaints increased recently? *

1.3 Do you have similar complaints while resting? *

1.4 Did you experience angina pectoris again, despite a bypass-operation, angioplasty or laser therapy? *

2.0 Did you suffer from a heart attack or cardiac arrest? *

2.1 Did you experience any complications afterwards? *

2.1a Which complications?

2.2 Do you still experience complaints? *

2.3 Did you suffer from a heart attack in the previous 6 months? *

3.0 Do you suffer from a heart murmur, cardiac valve/ventricle problems? *

4.0 Do you have an artificial hip or artificial heart valve (annuloplasty)? *

5.0 Did you undergo vascular surgery in the previous 6 months? *

5.1 Do you require antibiotics during dental treatment? *

5.2 Do you have any complaints as a result of your annuloplasty and/or heart valve replacement? *

6.0 Do you experience any palpitations or signs of an increased heart rate while in rest position? *

6.1. Do you need to lay down or sit down between seizures? *

6.2 Do you become pale, dizzy or get short of breath during seizures? *

7.0 Do you suffer from any kind of heart failure or waekness? *

7.1 Do you experience swollen feet at night? *

7.2 Do you have to urinate more than 2-times per night? *

7.3 Do you have to sleep with more than two pillows, because you otherwise get short of breath or wheezy? *

7.4 Do you wake up at night as a result of being short of breath? *

8.0 Do you have a high blood pressure? *

8.1 Is your systolic value usually between 160 and 200? *

8.2 Is your diastolic value usually between 95 and 115? *

8.3 Is your systolic value usually 200 or higher? *

8.4 Is your diastolic value usually 115 or higher? *

9.0 Did you experience any type of paralysis (stroke or attack) or speech impediments? *

9.1 Did you experience any similar type of complaints that lasted less 24 hours? *

9.2 Did you experience any type of paralysis (stroke or attack) over the last 6 months? *

10.0 Have you ever passed out during dental or any medical treatment? *

11.0 Do you use medicine against epilepsy? *

11.1 Do you regularly change your medication? *

11.2 Do you regularly suffer from seizures despite your usage of medicine? *

12.0 Do you suffer from hyperventilation? *

13.0 Do you suffer from asthma? *

13.1 Do you currently suffer from asthma? *

14.0 Are your lungs in bad condition? *

14.1 Do you cough up more than one coffee cup of mucus or phlegm per day? *

14.2 Are you out of breath while climbing the stairs after about 20 steps? *

14.3 Do you experience short of breath while dressing? *

15.0 Do you suffer from pollinosis – hay fever? *

16.0 Have you ever experienced an allergic reaction after using specific medicines or after using medical substances/products such as iodine, rubber, or band aids? *

16.1 Do you use medicines for your allergies? *

16.2 Are you allergic to penicillin or antibiotics? *

16.3 Did your allergy occur while receiving local anesthetics? *

16.4 Did your allergy occur while visiting your dentist? *

16.5 Can you be specific about your allergies you are currently suffering from? *

16.5a Which allergies? *

17.0 Do you have diabetes? *

17.1 Are you using insulin? *

17.2 Are you regularly distraught (hypertense/hyperglycemia)? *

17.3 Are you currently receiving treatment for cardiovascular complications as a result of diabetes? *

18.0 Are you diagnosed with an enhanced thyroid function? *

18.1 Are you currently being treated or under control for this? *

18.2 Do you suffer from complaints despite the treatment? *

19.0 Have you been diagnosed with a reduced thyroid function? *

19.1 Are you currently being treated or under control for this? *

19.2 Do you suffer from complaints despite the treatment? *

20.0 Do you suffer from any type of liver disease? *

20.1 Have you suffered from this liver disease for more than six months? *

20.2 Are you on a specific diet or are taking any medicines because of this liver disease? *

21.0 Do you suffer from a chronic kidney disease which requires you to follow a specific diet? *

21.1 Do you have renal replacement therapy? *

22.0 Do you suffer from chronic stomach complaints and as a result have lost more than 5 kilograms in weight? *

22.1 Are you experiencing diarrhea for more than 6 months? *

23.0 Are you currently suffering from any type of contagious disease? *

23.1 Do you know which contagious disease? *

23.1a Which? *

24.0 Do you suffer from anemia combined with complaints (fatigue/dizziness)? *

25.0 Are you suffering from any type of malignant lymph node or blood disease? *

25.1 Do you know which malignant disease? *

25.1a Which? *

25.2 Are you currently being treated for this disease? *

25.3 Are you suffering from fever during seizures? *

26.0 Are you prone to an elevated level of haemorrhage or tend to bleed? *

26.1 Does the bleeding last more than 1 hour in your experience after the injury or treatment? *

26.2 Do you bruise easily or spontaneous? *

27.0 Did you receive any type of radiation for any kind of tumor, abscess or swelling on your head or neck? *

27.1 Was this radiation done within the last 5 years? *

28. Are you using any type of medicines at the moment? *

28.1 For your heart? *

28.2 Are you receiving any treatment for thrombosis? *

28.3 For high blood pressure? *

28.4 Aspirins or pain-relieving drugs/analgesics? *

28.5 For diabetes? *

28.6 Prednison, corticosteroids or any other anti-inflammatory agents? *

28.7 Medicines against cancer or bleeding diseases? *

28.8 Penicillin or antibiotics? *

28.9 Sedatives, sleeping pills, antidepressants? *

28.10 Do you use any other medicine? *

28.10a Which other medicine? *

28.11 Do you use sedative drugs daily? *

28.12 Consume more than 5 alcoholic bevereages per day? *

28.13 Prefention of bone decalcification (osteroporosis). If YES: how long have you been using these medicines? *

28.13a How long *

29.0 Are you a smoker? *

29.1 Do you how much a day? *

29.1a How much? *

30.0 Are you currently undergoing treatment in a hospital, or have recently visited a hospital, for injections to prevent bone decalcification (osteoporosis)? *

31.0 I give permission to process data about me and my health in the context of the oral care to be provided *

Agree

I give permission to process data about me and my health in the context of the oral care to be provided. This permission also includes: I. the processing of personal data present in my patient file; II. providing my personal data to third parties in the context of the processing of declarations; III. providing my personal data to other healthcare providers, insofar as this is necessary in the context of my treatment.

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