Medical intake child

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Medical intake child

Name*
First name Last name
Email*
Phone*
Date of birth*
Citizen service number (BSN)*
Family doctor*
Previous Dentist (if applicable)
Did your child have cavities in the past 5 years?*
- Yes
- No
Does you child have senstive teeth?*
- Yes
- No
Are there particularities regarding the change of the primary teeth?*
- Yes
- No
Namely
Is your child seeing an orthodontist?*
- Yes
- No
Did your child ever fall on the front teeth or chin?*
- Yes
- No
Are there other things regarding the teeth we can take into account?*
- Yes
- No
Namely
Is your child allergic?*
- Yes
- No
Namely
Did you breastfeed your child?*
- Yes
- No
Was your child born with heart failure?*
- Yes
- No
Is your child diagnosed with epilepsy?*
- Yes
- No
Does your child have a lung disease such as asthma or bronchitis?*
- Yes
- No
Is your child diabetic?*
- Type 1
- Type 2
- No
Does your child have anemia?*
- Yes
- No
Does your child have hepatitis or a liver disease?*
- Yes
- No
Does you child have a kidney disease?*
- Yes
- No
Does your child have problems eating or gastrointestinal complaints?*
- Yes
- No
Does your child experience behavioral problems? (such as anxiety or hyperactiveness)*
- Yes
- No
Namely
Is your child attending special education or medical daycare?*
- Yes
- No
Is your child using medication?*
- 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
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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