PKDH – ENG

Health Questionnaire

1Introduction

2Personal Data

3Insurance Data

4Specialists Data

5Questionnaire

6Signature

Health questionnaire and personal details

A number of diseases and physical defects, the use of medication and certain life style choices may have a (pronounced) effect on your oral health.
They may also limit your dental treatment, or necessitate certain precautionary measures.

It is, therefore - in your interest - very important that we are fully aware of these facts and able to assess any potential risks.

By completing the following questionnaire, based on the EMRRH-system (European Medical Risk Related History), you supply us with the necessary information.

Your data will be treated confidentially and is covered by medical professional secrecy. This is done in accordance with the Medical Treatment Contracts Act (Wgbo) and the General Data Protection Regulation (Avg).

Lay-out of the questionnaire
We will first ask certain details that are necessary for the administrative process, such as your name, address and your insurance details. Please make sure you have those details at hand. Subsequently, we will ask after your current state of health.

How much time will completing the questionnaire take?
The questionnaire contains 38 main questions. In case of a confirming answer, you will be asked for a clarification.
You will only need to click on the relevant options.
By completing the questionnaire at home in peace, your appointment will also be 15 minutes shorter.

What is your patient registration number?

Your patient number (from our clinic) which you have received in your email.

What is your surname? *

What is your first name? *

Initials? *

Gender? *

Male
Female

Home address? *

House number? *

Postal code? *

Town/City? *

Email address? *

Date of birth? *

Social security number?

What is your profession?

Home telephone number?

Mobile phone number? *

Business telephone number?

What is the name of your medical insurance company?

Insurer's UZOVI code?

The 'Unieke ZorgVerzekeraarsIdentificatie' (UZOVI) is an identification code of the healthcare insurers in the Netherlands. Healthcare providers and insurers use this UZOVI-code when settling the costs.

Do you have additional dental cover?

Registration number?

Name and address of your dentist?

Name and address of your general medical practitioner?

Name and address of other specialists?

Name and address of your dispensing pharmacist?

I consent to the exchange of information between our clinic and the above-mentioned practitioners.

Questions

1 Do you experience chest pain or tightness around the chest upon exertion (angina pectoris)?

1a If so, have you had to limit your activities?

1b If so, do you have chest pain at rest?

1c If so, have the complaints increased recently?

2 Have you ever had a heart attack?

2a If so, have you had to limit your activities?

2b If so, have you had a heart attack in the last six months?

3 Do you have a heart murmur or heart valve disease?

3a Do you have an artificial heart valve?

3b If so, have you had to limit your activities?

4 Have you had heart or vascular surgery within the last six months?

5 Do you have a Pacemaker or ICD (internal cardioverter defibrillator)

6 Do you have heart palpitations without exertion?

6a If so, do you have to rest, sit or lie down during these palpitations?

6b If so, are you pale, dizzy or short of breath during these palpitations?

7 Do you suffer from heart failure?

7a If so, are you short of breath when lying flat?

7b If so, do you need more than two pillows at night?

8 Do you have, or have you ever had high blood pressure?

8a If so, do you use hypotensive medication?

8b If so, what are your systolic and diastolic values on medication?

9 Do you have an abnormal bleeding tendency?

9a If so, do you bleed for longer than 1 hour following injury or surgery

9b If so, do you suffer from spontaneous bruising?

10 Do you suffer from epilepsy?

10a If so, do you continue to have attacks regularly, despite medication?

10b If so, do you change your medication often?

11 Do you suffer from asthma?

11a If so, do you use any medication or inhalers?

11b If so, is your breathing often difficult?

12 Do you have any other lung problems or a persistent cough?

12a Are you short of breath after climbing 20 steps?

12b Are you sort of breath getting dressed?

13 Have you ever had an allergic reaction?

13a To penicillin, aspirin or other medication?

13b To latex (gloves) or dental/medical materials?

13c Did you require medical or hospital treatment during such an episode?

13d Did a local anaesthetic trigger the allergic reaction?

13e Did the allergic reaction occur during a dental treatment?

13f What are you allergic to?

14 Do you suffer from diabetes?

14a If so, are you on insuline?

14b If so, is your diabetes poorly controlled at present (hypoglycaemia or hyperglycaemia)?

15 Do you suffer from thyroid disease?

15a If so, is your thyroid underactive?

15b If so, is your thyroid overactive?

15c Is your thyroid function (with medication) optimal?

16 Are you currently suffering from, or have you ever suffered from a liver disease? (Hepatitis A, B or C)

16a If so, are you on a specific diet or taking medication?

17 Do you suffer from kidney disease?

17a If so, are you undergoing dialysis?

17b If so, do you have a kidney transplant?

18 Do you suffer from, or have you ever suffered from malignant disease (cancer) or a blood- disease?

18a If so, which?

18b If so, are you undergoing treatment at present?

18c If so, have you had radiation treatment of a tumor or growth in the head or neck?

18d If you ever had radiation treatment to the head or neck, when was this?

18e Have you had chemotherapy for any form of cancer?

18f If so, what for?

18g If so, when?

19 Do you suffer from hyperventilation?

20 Have you ever fainted during dental or medical treatment?

21 Are you anaemic and do you suffer from side-effects (tiredness, dizziness)?

22 Are you using any prescribed or over-the-counter medication?

For a heart complaint?
Against high blood pressure?
Anticoagulants?
Are your getting intensive care for thrombotic patients?
Aspirin or other painkillers?
For diabetes?
Medication for hay fever?
Prednisone or corticosteroids (systemic or topical)?
Drugs against transplant rejection?
Drugs against skin diseases?
Drugs against bowel diseases?
Drugs against rheumatic diseases?
For cancer or blood disease?
Penicillin or other antibiotics?
Sleeping pills or tranquillizers?
Anti-depressants or narcotics?
Are you currently using, or have you used medication in the past to prevent osteoporosis? (bisphosphonate)
Any other medication?

Opt-in if it applies to you.

For a heart complaint: *

Dosage: *

Against high blood pressure: *

Dosage: *

Anticoagulants: *

Dosage: *

Aspirin or other painkillers: *

Dosage: *

For diabetes: *

Dosage: *

Medication for hay fever: *

Dosage: *

Prednisone or corticosteroids (systemic or topical): *

Dosage: *

Drugs against transplant rejection: *

Dosage: *

Drugs against skin diseases: *

Dosage: *

Drugs against bowel diseases: *

Dosage: *

Drugs against rheumatic diseases: *

Dosage: *

For cancer or blood disease: *

Dosage: *

Penicillin or other antibiotics: *

Dosage: *

Sleeping pills or tranquillizers: *

Dosage: *

Anti-depressants or narcotics: *

Dosage: *

Medication to prevent osteoporosis: (bisphosphonate) *

Dosage: *

Any other medication:

23 Are you, or might you be pregnant?

24 Do you have a contagious disease?

24a If so, please mention the disease:

25 Are you being treated by a physician, medical specialist, psychologist or psychiatrist?

25a If so, please specify the specialist:

26 Do you suffer from stress?

26a Can you coop with this stress?

27 Would you describe your lifestyle as healthy?

28 Are you overtired?

29 Do you have a low resistance?

30 Do you use (recreational) drugs?

30a If so, what drugs are you using and how often?

31 On average, do you drink more than two glasses of alcohol per day?

32 Do you currently smoke or have you smoked in the past?

32a How many cigarettes and/or cigars per day?

32b When did you stop smoking?

33 Do you grind or clench your teeth?

34 Does anyone in your family suffer from periodontitis?

35 Do you suffer from halitosis (bad breath)?

36 Do you suffer from any other disease or medical condition that we failed to ask for, which you believe to be of importance in this respect?

36a If so, which disease or medical problem is this? *

37 I agree with the cost estimate and the general conditions of our clinic (see email or letter) *

Agree
Disagree

37a Date: *

37b Place *

38 This questionnaire has been completed truthfully: *

39 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.

Signature

Signature *

Date *