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 In order to provide good medical/dental care, we will collect a health questionnaire from you. We include the contact details and medical details in your patient card. We do this in line with the Medical Treatment Contracts Act (Wgbo) and the General Data Protection Regulation (Avg). This means that we only use your data for the provision of medical care and the associated administration and that we protect your data against infringement by third parties. We keep your data for as long as necessary for the provision of care and for as long as the law obliges us to keep your data. This is at least 15 years. After this period we will delete your data. Information about the processing of your data can be found at the beginning of the health questionnaire and on the website on our website. We exchange data with other healthcare providers, such as general practitioners, pharmacies, hospitals, etc. only if you give permission to do so. Your data will only be consulted when necessary for the performance of tasks for your treatment. Your rights: You have the right to inspect your data. If it appears that information about you is incorrect, you have the right to have it corrected or removed by us. It may happen that it is not possible to (fully) comply with a request (for example if your access leads to an infringement of the privacy of others). If you would like to view your details, please contact one of our employees at the desk. You can receive a copy of the results of the health questionnaire free of charge at your request. These are provided to you personally. Complaints: If you have complaints or compliments about the way in which we treat your data, please contact our employees at the desk. If you cannot reach agreement about your complaint, you have the right to submit a complaint to the Dutch Data Protection Authority.

I have read the above privacy statement and agree that my data will be used for the treatment *

Agree

Signature*

Date*