Medical intake adult

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Medical intake adult

Titel*
Name*
First name Last name
Date of birth*
Citizen service number (BSN)*
Address*
Address + house number City Zip code
Email*
Phone number*
Occupation
Family doctor*
Previous dentist*
How did you find us?
- Family / friends
- Internet
When was your last dentist visit?
- Less than a month
- 1-6 months
- 6-12 months
- 1-3 years
- Never
How often do you visit the dentist?
- More often than 2 times per year
- 2 times per year
- 1 time per year
- less then once per year
Are you afraid of the dentist?
- Anxious
- Little Anxious
- Not Anxious
Are you happy with your teeth?
- Very satisfied
- Satisfied
- Dissatisfied
How important are your teeth for you?
- Very important
- Important
- Not important
Do your gums often bleed while cleaning your teeth?
- Yes
- No
Have you ever been treated for gum disease?*
- Yes
- No
Namely
Does periodontitis occur in your family?*
- Yes
- No
Have you had any cavities within the last 5 years?*
- Yes
- No
Do you have sensitive teeth?*
- Yes
- No
Do you frequently get food caught in between your teeth?*
- Yes
- No
Do you have problems/questions regarding your teeth/gums/smile/mouth?
Do you have problems with your jaw joint?*
- Yes
- No
Have your teeth changed (form or position) in the last 5 years?*
- Yes
- No
Do you have little saliva or difficulty swallowing (food)?*
- Yes
- No
Is there anything about the appearance of your teeth that you would like to change?*
- Yes
- No
Namely
Are you being treated by a doctor or medical specialist?*
- Yes
- No
Are you allergic?*
- Yes
- No
Namely
Have you had a heart attack?*
- Yes
- No
When
Do you suffer from heart palpitations?*
- Yes
- No
Are you being treated for high blood pressure?*
- Yes
- No
For
- Top pressure
- Bottom pressure
Do you have chest pain during physical exertion and/or emotions?*
- Yes
- No
Are you short of breath when lying flat?*
- Yes
- No
Do you have a heart valve defect, an artificial heart valve or hip?*
- Yes
- No
Do you have a congenital heart defect?*
- Yes
- No
Do you have a pacemaker?*
- Yes
- No
Have you ever fainted at the doctor/dentist?*
- Yes
- No
Do you experience hyperventilation?*
- Yes
- No
Are you diagnosed with epilepsy?*
- Yes
- No
Have you ever had a stroke?*
- Yes
- No
If so, when
Do you have a lung disease such as asthma or bronchitis?*
- Yes
- No
Do you have diabetes?*
- Yes, Type I
- Yes, Type II
- No
Do you have anemia?*
- Yes
- No
Have you ever had a prolonged bleeding after surgery?*
- Yes
- No
Do you have hepatitis, jaundice or other liver disease?*
- Yes
- No
Do you suffer from kidney disease?*
- Yes
- No
Do you have rheumatoid arthritis and/or chronic joint problems?*
- Yes
- No
Are you irradiated because of a tumor in the neck and/or head?*
- Yes
- No
Are you being monitored for thrombosis?*
- Yes
- No
Do you use anticoagulants?*
- Yes
- No
Do you smoke?*
- Yes
- No
How many a day?
Do you use alcohol?*
- Yes
- No
How many a week?
Do you suffer from depression or dejection?*
- Yes
- No
Have you ever experienced a serious illness?*
- Yes
- No
Namely
Do you currently have an infectious disease?*
- Yes
- No
Namely
Do you have a disease not mentioned above?*
- Yes
- No
Namely
Are you pregnant?
- Yes
- No
Are you currently breastfeeding?
- Yes
- No
Do you currently use any medication?*
- Yes
- No
Namely
Do you have a preference for a day/time to make the first appointment?
Are there things that we can take into account? Or do you have any other questions?*
- Yes
- No
Namely
I confirm that:*
- I have read and agree to the house rules
- Florens Tandartsen stores and processes my information for dental for purpose
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