De Amsterdamse Tandarts

First Name*

Last Name*

Date of Birth*

E-mail address*

Mobile number*

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

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

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?*

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

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

8.0 Do you have a high blood pressure?*

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

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

11.0 Do you use medicine against epilepsy?*

12.0 Do you suffer from hyperventilation?*

13.0 Do you suffer from asthma?*

14.0 Are your lungs in bad condition?*

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?*

17.0 Do you have diabetes?*

18.0 Are you diagnosed with an enhanced thyroid function?*

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

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

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

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

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

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?*

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

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

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

29.0 Do you smoke?*

30.0 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 processing invoices; III. providing my personal data to other healthcare providers, insofar as this is necessary in the context of my treatment.*

Agree

Signature*

Date*