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)?*YesNo{"groups":[{"groupOp":"AND","groupAction":"show","rules":[{"field":"1_0_Do_you_experience_any_pain_or_pressure_in_your_chest_during_mild_effort__angina_pectoris__","op":"eq","data":"Ja"}]}]}1.1 Did you have to reduce your activity level?*YesNo{"groups":[{"groupOp":"AND","groupAction":"show","rules":[{"field":"1_0_Do_you_experience_any_pain_or_pressure_in_your_chest_during_mild_effort__angina_pectoris__","op":"eq","data":"Ja"}]}]}1.2 Have above mentioned complaints increased recently?*YesNo{"groups":[{"groupOp":"AND","groupAction":"show","rules":[{"field":"1_0_Do_you_experience_any_pain_or_pressure_in_your_chest_during_mild_effort__angina_pectoris__","op":"eq","data":"Ja"}]}]}1.3 Do you have similar complaints while resting?*YesNo{"groups":[{"groupOp":"AND","groupAction":"show","rules":[{"field":"1_0_Do_you_experience_any_pain_or_pressure_in_your_chest_during_mild_effort__angina_pectoris__","op":"eq","data":"Ja"}]}]}1.4 Did you experience angina pectoris again, despite a bypass-operation, angioplasty or laser therapy?*YesNo2.0 Did you suffer from a heart attack or cardiac arrest?*YesNo{"groups":[{"groupOp":"AND","groupAction":"show","rules":[{"field":"2_0_Did_you_suffer_from_a_heart_attack_or_cardiac_arrest_","op":"eq","data":"Ja"}]}]}2.1 Did you experience any complications afterwards?*YesNo{"groups":[{"groupOp":"AND","groupAction":"show","rules":[{"field":"2_1_Did_you_experience_any_complications_afterwards_","op":"eq","data":"Ja"}]}]}2.1a Which complications?*{"groups":[{"groupOp":"AND","groupAction":"show","rules":[{"field":"2_0_Did_you_suffer_from_a_heart_attack_or_cardiac_arrest_","op":"eq","data":"Ja"}]}]}2.2 Do you still experience complaints?*YesNo{"groups":[{"groupOp":"AND","groupAction":"show","rules":[{"field":"2_0_Did_you_suffer_from_a_heart_attack_or_cardiac_arrest_","op":"eq","data":"Ja"}]}]}2.3 Did you suffer from a heart attack in the previous 6 months?*YesNo3.0 Do you suffer from a heart murmur, cardiac valve/ventricle problems?*YesNo4.0 Do you have an artificial hip or artificial heart valve (annuloplasty)?*YesNo5.0 Did you undergo vascular surgery in the previous 6 months?*YesNo{"groups":[{"groupOp":"AND","groupAction":"show","rules":[{"field":"5_0_Did_you_undergo_vascular_surgery_in_the_previous_6_months_","op":"eq","data":"Ja"}]}]}5.1 Do you require antibiotics during dental treatment?*YesNo{"groups":[{"groupOp":"AND","groupAction":"show","rules":[{"field":"5_0_Did_you_undergo_vascular_surgery_in_the_previous_6_months_","op":"eq","data":"Ja"}]}]}5.2 Do you have any complaints as a result of your annuloplasty and/or heart valve replacement?*YesNo6.0 Do you experience any palpitations or signs of an increased heart rate while in rest position?*YesNo{"groups":[{"groupOp":"AND","groupAction":"show","rules":[{"field":"6_0_Do_you_experience_any_palpitations_or_signs_of_an_increased_heart_rate_while_in_rest_position_","op":"eq","data":"Ja"}]}]}6.1 Do you need to lay down or sit down between seizures?*YesNo{"groups":[{"groupOp":"AND","groupAction":"show","rules":[{"field":"6_0_Do_you_experience_any_palpitations_or_signs_of_an_increased_heart_rate_while_in_rest_position_","op":"eq","data":"Ja"}]}]}6.2 Do you become pale, dizzy or get short of breath during seizures?*YesNo7.0 Do you suffer from any kind of heart failure or waekness?*YesNo{"groups":[{"groupOp":"AND","groupAction":"show","rules":[{"field":"7_0_Do_you_suffer_from_any_kind_of_heart_failure_or_waekness_","op":"eq","data":"Ja"}]}]}7.1 Do you experience swollen feet at night?*YesNo{"groups":[{"groupOp":"AND","groupAction":"show","rules":[{"field":"7_0_Do_you_suffer_from_any_kind_of_heart_failure_or_waekness_","op":"eq","data":"Ja"}]}]}7.2 Do you have to urinate more than 2-times per night?*YesNo{"groups":[{"groupOp":"AND","groupAction":"show","rules":[{"field":"7_0_Do_you_suffer_from_any_kind_of_heart_failure_or_waekness_","op":"eq","data":"Ja"}]}]}7.3 Do you have to sleep with more than two pillows, because you otherwise get short of breath or wheezy?*YesNo{"groups":[{"groupOp":"AND","groupAction":"show","rules":[{"field":"7_0_Do_you_suffer_from_any_kind_of_heart_failure_or_waekness_","op":"eq","data":"Ja"}]}]}7.4 Do you wake up at night as a result of being short of breath?*YesNo8.0 Do you have a high blood pressure?*YesNo{"groups":[{"groupOp":"AND","groupAction":"show","rules":[{"field":"8_0_Do_you_have_a_high_blood_pressure_","op":"eq","data":"Ja"}]}]}8.1 Is your systolic value usually between 160 and 200?*YesNo{"groups":[{"groupOp":"AND","groupAction":"show","rules":[{"field":"8_0_Do_you_have_a_high_blood_pressure_","op":"eq","data":"Ja"}]}]}8.2 Is your diastolic value usually between 95 and 115?*YesNo{"groups":[{"groupOp":"AND","groupAction":"show","rules":[{"field":"8_0_Do_you_have_a_high_blood_pressure_","op":"eq","data":"Ja"}]}]}8.3 Is your systolic value usually 200 or higher?*YesNo{"groups":[{"groupOp":"AND","groupAction":"show","rules":[{"field":"8_0_Do_you_have_a_high_blood_pressure_","op":"eq","data":"Ja"}]}]}8.4 Is your diastolic value usually 115 or higher?*YesNo9.0 Did you experience any type of paralysis (stroke or attack) or speech impediments?*YesNo{"groups":[{"groupOp":"AND","groupAction":"show","rules":[{"field":"9_0_Did_you_experience_any_type_of_paralysis__stroke_or_attack__or_speech_impediments_","op":"eq","data":"Ja"}]}]}9.1 Did you experience any similar type of complaints that lasted less 24 hours?*YesNo{"groups":[{"groupOp":"AND","groupAction":"show","rules":[{"field":"9_0_Did_you_experience_any_type_of_paralysis__stroke_or_attack__or_speech_impediments_","op":"eq","data":"Ja"}]}]}9.2 Did you experience any type of paralysis (stroke or attack) over the last 6 months?*YesNo10.0 Have you ever passed out during dental or any medical treatment?*YesNo11.0 Do you use medicine against epilepsy?*YesNo{"groups":[{"groupOp":"AND","groupAction":"show","rules":[{"field":"11_0_Do_you_use_medicine_against_epilepsy_","op":"eq","data":"Ja"}]}]}11.1 Do you regularly change your medication?*YesNo{"groups":[{"groupOp":"AND","groupAction":"show","rules":[{"field":"11_0_Do_you_use_medicine_against_epilepsy_","op":"eq","data":"Ja"}]}]}11.2 Do you regularly suffer from seizures despite your usage of medicine?*YesNo12.0 Do you suffer from hyperventilation?*YesNo13.0 Do you suffer from asthma?*YesNo{"groups":[{"groupOp":"AND","groupAction":"show","rules":[{"field":"13_0_Do_you_suffer_from_asthma_","op":"eq","data":"Ja"}]}]}13.1 Do you currently suffer from asthma?*YesNo14.0 Are your lungs in bad condition?*YesNo{"groups":[{"groupOp":"AND","groupAction":"show","rules":[{"field":"14_0_Are_your_lungs_in_bad_condition_","op":"eq","data":"Ja"}]}]}14.1 Do you cough up more than one coffee cup of mucus or phlegm per day?*YesNo{"groups":[{"groupOp":"AND","groupAction":"show","rules":[{"field":"14_0_Are_your_lungs_in_bad_condition_","op":"eq","data":"Ja"}]}]}14.2 Are you out of breath while climbing the stairs after about 20 steps?*YesNo{"groups":[{"groupOp":"AND","groupAction":"show","rules":[{"field":"14_0_Are_your_lungs_in_bad_condition_","op":"eq","data":"Ja"}]}]}14.3 Do you experience short of breath while dressing?*YesNo15.0 Do you suffer from pollinosis – hay fever?*YesNo16.0 Have you ever experienced an allergic reaction after using specific medicines or after using medical substances/products such as iodine, rubber, or band aids?*YesNo{"groups":[{"groupOp":"AND","groupAction":"show","rules":[{"field":"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_","op":"eq","data":"Ja"}]}]}16.1 Do you use medicines for your allergies?*YesNo{"groups":[{"groupOp":"AND","groupAction":"show","rules":[{"field":"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_","op":"eq","data":"Ja"}]}]}16.2 Are you allergic to penicillin or antibiotics?*YesNo{"groups":[{"groupOp":"AND","groupAction":"show","rules":[{"field":"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_","op":"eq","data":"Ja"}]}]}16.3 Did your allergy occur while receiving local anesthetics?*YesNo{"groups":[{"groupOp":"AND","groupAction":"show","rules":[{"field":"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_","op":"eq","data":"Ja"}]}]}16.4 Did your allergy occur while visiting your dentist?*YesNo{"groups":[{"groupOp":"AND","groupAction":"show","rules":[{"field":"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_","op":"eq","data":"Ja"}]}]}16.5 Can you be specific about your allergies you are currently suffering from?*YesNo{"groups":[{"groupOp":"AND","groupAction":"show","rules":[{"field":"16_5_Can_you_be_specific_about_your_allergies_you_are_currently_suffering_from_","op":"eq","data":"Ja"}]}]}16.5a Which allergies?*17.0 Do you have diabetes?*YesNo{"groups":[{"groupOp":"AND","groupAction":"show","rules":[{"field":"17_0_Do_you_have_diabetes_","op":"eq","data":"Ja"}]}]}17.1 Are you using insulin?*YesNo{"groups":[{"groupOp":"AND","groupAction":"show","rules":[{"field":"17_0_Do_you_have_diabetes_","op":"eq","data":"Ja"}]}]}17.2 Are you regularly distraught (hypertense/hyperglycemia)?*YesNo{"groups":[{"groupOp":"AND","groupAction":"show","rules":[{"field":"17_0_Do_you_have_diabetes_","op":"eq","data":"Ja"}]}]}17.3 Are you currently receiving treatment for cardiovascular complications as a result of diabetes?*YesNo18.0 Are you diagnosed with an enhanced thyroid function?*YesNo{"groups":[{"groupOp":"AND","groupAction":"show","rules":[{"field":"18_0_Are_you_diagnosed_with_an_enhanced_thyroid_function_","op":"eq","data":"Ja"}]}]}18.1 Are you currently being treated or under control for this?*YesNo{"groups":[{"groupOp":"AND","groupAction":"show","rules":[{"field":"18_0_Are_you_diagnosed_with_an_enhanced_thyroid_function_","op":"eq","data":"Ja"}]}]}18.2 Do you suffer from complaints despite the treatment?*YesNo19.0 Have you been diagnosed with a reduced thyroid function?*YesNo{"groups":[{"groupOp":"AND","groupAction":"show","rules":[{"field":"19_0_Have_you_been_diagnosed_with_a_reduced_thyroid_function_","op":"eq","data":"Ja"}]}]}19.1 Are you currently being treated or under control for this?*YesNo{"groups":[{"groupOp":"AND","groupAction":"show","rules":[{"field":"19_0_Have_you_been_diagnosed_with_a_reduced_thyroid_function_","op":"eq","data":"Ja"}]}]}19.2 Do you suffer from complaints despite the treatment?*YesNo20.0 Do you suffer from any type of liver disease?*YesNo{"groups":[{"groupOp":"AND","groupAction":"show","rules":[{"field":"20_0_Do_you_suffer_from_any_type_of_liver_disease_","op":"eq","data":"Ja"}]}]}20.1 Have you suffered from this liver disease for more than six months?*YesNo{"groups":[{"groupOp":"AND","groupAction":"show","rules":[{"field":"20_0_Do_you_suffer_from_any_type_of_liver_disease_","op":"eq","data":"Ja"}]}]}20.2 Are you on a specific diet or are taking any medicines because of this liver disease?*YesNo21.0 Do you suffer from a chronic kidney disease which requires you to follow a specific diet?*YesNo{"groups":[{"groupOp":"AND","groupAction":"show","rules":[{"field":"21_0_Do_you_suffer_from_a_chronic_kidney_disease_which_requires_you_to_follow_a_specific_diet_","op":"eq","data":"Ja"}]}]}21.1 Do you have renal replacement therapy?*YesNo22.0 Do you suffer from chronic stomach complaints and as a result have lost more than 5 kilograms in weight?*YesNo{"groups":[{"groupOp":"AND","groupAction":"show","rules":[{"field":"22_0_Do_you_suffer_from_chronic_stomach_complaints_and_as_a_result_have_lost_more_than_5_kilograms_in_weight_","op":"eq","data":"Ja"}]}]}22.1 Are you experiencing diarrhea for more than 6 months?*YesNo23.0 Are you currently suffering from any type of contagious disease?*YesNo{"groups":[{"groupOp":"AND","groupAction":"show","rules":[{"field":"23_0_Are_you_currently_suffering_from_any_type_of_contagious_disease_","op":"eq","data":"Ja"}]}]}23.1 Do you know which contagious disease?*YesNo{"groups":[{"groupOp":"AND","groupAction":"show","rules":[{"field":"23_1_Do_you_know_which_contagious_disease_","op":"eq","data":"Ja"}]}]}23.1a Which one(-s) specifically?*24.0 Do you suffer from anemia combined with complaints (fatigue/dizziness)?*YesNo25.0 Are you suffering from any type of malignant lymph node or blood disease?*YesNo{"groups":[{"groupOp":"AND","groupAction":"show","rules":[{"field":"25_0_Are_you_suffering_from_any_type_of_malignant_lymph_node_or_blood_disease_","op":"eq","data":"Ja"}]}]}25.1 Do you know which malignant disease?*YesNo{"groups":[{"groupOp":"AND","groupAction":"show","rules":[{"field":"25_1_Do_you_know_which_malignant_disease_","op":"eq","data":"Ja"}]}]}25.1a Which?*{"groups":[{"groupOp":"AND","groupAction":"show","rules":[{"field":"25_0_Are_you_suffering_from_any_type_of_malignant_lymph_node_or_blood_disease_","op":"eq","data":"Ja"}]}]}25.2 Are you currently being treated for this disease?*YesNo{"groups":[{"groupOp":"AND","groupAction":"show","rules":[{"field":"25_0_Are_you_suffering_from_any_type_of_malignant_lymph_node_or_blood_disease_","op":"eq","data":"Ja"}]}]}25.3 Are you suffering from fever during seizures?*YesNo26.0 Are you prone to an elevated level of haemorrhage or tend to bleed?*YesNo{"groups":[{"groupOp":"AND","groupAction":"show","rules":[{"field":"26_0_Are_you_prone_to_an_elevated_level_of_haemorrhage_or_tend_to_bleed_","op":"eq","data":"Ja"}]}]}26.1 Does the bleeding last more than 1 hour in your experience after the injury or treatment?*YesNo{"groups":[{"groupOp":"AND","groupAction":"show","rules":[{"field":"26_0_Are_you_prone_to_an_elevated_level_of_haemorrhage_or_tend_to_bleed_","op":"eq","data":"Ja"}]}]}26.2 Do you bruise easily or spontaneous?*YesNo27.0 Did you receive any type of radiation for any kind of tumor, abscess or swelling on your head or neck?*YesNo{"groups":[{"groupOp":"AND","groupAction":"show","rules":[{"field":"27_0_Did_you_receive_any_type_of_radiation_for_any_kind_of_tumor__abscess_or_swelling_on_your_head_or_neck_","op":"eq","data":"Ja"}]}]}27.1 Was this radiation done within the last 5 years?*YesNo28.0 Are you using any type of medicines at the moment?*YesNo{"groups":[{"groupOp":"AND","groupAction":"show","rules":[{"field":"28_0_Are_you_using_any_type_of_medicines_at_the_moment_","op":"eq","data":"Ja"}]}]}28.1 For your heart?*YesNo{"groups":[{"groupOp":"AND","groupAction":"show","rules":[{"field":"28_0_Are_you_using_any_type_of_medicines_at_the_moment_","op":"eq","data":"Ja"}]}]}28.2 Are you receiving any treatment for thrombosis?*YesNo{"groups":[{"groupOp":"AND","groupAction":"show","rules":[{"field":"28_0_Are_you_using_any_type_of_medicines_at_the_moment_","op":"eq","data":"Ja"}]}]}28.3 For high blood pressure?*YesNo{"groups":[{"groupOp":"AND","groupAction":"show","rules":[{"field":"28_0_Are_you_using_any_type_of_medicines_at_the_moment_","op":"eq","data":"Ja"}]}]}28.4 Aspirins or pain-relieving drugs/analgesics?*YesNo{"groups":[{"groupOp":"AND","groupAction":"show","rules":[{"field":"28_0_Are_you_using_any_type_of_medicines_at_the_moment_","op":"eq","data":"Ja"}]}]}28.5 For diabetes?*YesNo{"groups":[{"groupOp":"AND","groupAction":"show","rules":[{"field":"28_0_Are_you_using_any_type_of_medicines_at_the_moment_","op":"eq","data":"Ja"}]}]}28.6 Prednison, corticosteroids or any other anti-inflammatory agents?*YesNo{"groups":[{"groupOp":"AND","groupAction":"show","rules":[{"field":"28_0_Are_you_using_any_type_of_medicines_at_the_moment_","op":"eq","data":"Ja"}]}]}28.7 Medicines against cancer or bleeding diseases?*YesNo{"groups":[{"groupOp":"AND","groupAction":"show","rules":[{"field":"28_0_Are_you_using_any_type_of_medicines_at_the_moment_","op":"eq","data":"Ja"}]}]}28.8 Penicillin or antibiotics?*YesNo{"groups":[{"groupOp":"AND","groupAction":"show","rules":[{"field":"28_0_Are_you_using_any_type_of_medicines_at_the_moment_","op":"eq","data":"Ja"}]}]}28.9 Sedatives, sleeping pills, antidepressants?*YesNo{"groups":[{"groupOp":"AND","groupAction":"show","rules":[{"field":"28_0_Are_you_using_any_type_of_medicines_at_the_moment_","op":"eq","data":"Ja"}]}]}28.10 Are you using any other type of medicine(-s)?*YesNo{"groups":[{"groupOp":"AND","groupAction":"show","rules":[{"field":"28_10_Are_you_using_any_other_type_of_medicine__s__","op":"eq","data":"Ja"}]}]}28.10a Which medicine(-s)?*{"groups":[{"groupOp":"AND","groupAction":"show","rules":[{"field":"28_0_Are_you_using_any_type_of_medicines_at_the_moment_","op":"eq","data":"Ja"}]}]}28.11 Do you use narcotic drugs daily?*YesNo{"groups":[{"groupOp":"AND","groupAction":"show","rules":[{"field":"28_0_Are_you_using_any_type_of_medicines_at_the_moment_","op":"eq","data":"Ja"}]}]}28.12 Consume more than 5 alcoholic beverages per day?*YesNo29.0 Do you smoke?*YesNo{"groups":[{"groupOp":"AND","groupAction":"show","rules":[{"field":"29_0_Do_you_smoke_","op":"eq","data":"Ja"}]}]}29.1 Do you know how many a day?*YesNo{"groups":[{"groupOp":"AND","groupAction":"show","rules":[{"field":"29_1_Do_you_know_how_many_a_day_","op":"eq","data":"Ja"}]}]}29.1a How many?*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.*AgreeSignature*Canvas is not supportedSendDate*