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Medical history

Medical History

You will be asked to complete a medical history list before your first appointment. This is important because many physical diseases and medicines can affect the prevention of problems with your teeth and the performance of dental work. If we are aware of your medical situation, we can take the right precautions. It is therefore important that you also inform us of any changes in your medical situation.

"N.B.: only fill in this form at the request of de Nieuwegracht"

My Website

Name

Date of birth

E-mail

Gender

Male Female Non-binary

Today's date

Have there been any changes in your health over the past couple of months?

Yes No

If so, what?

Are you currently receiving treatment from a doctor or medical specialist?

Yes No

If so, please specify

Have you been admitted to hospital in the past years?

Yes No

If so, please specify

Have you ever had a serious disease?

Yes No

If so, please specify

Do you have any allergies?

Yes No

If so, please specify

Have you had a heart attack/cardiac infarction?

Yes No

If so, when?

Do you suffer from palpitations?

Yes No

Are you being treated for high blood pressure?

Yes No

If so, what is your blood pressure?

Do you experience chest pain during exercise and/or emotions?

Yes No

Do you have swollen ankles/feet?

Yes No

Are you short of breath during exercises?

Yes No

Are you short of breath when you lay down in bed?

Yes No

Do you have a defective or an artificial heart valve?

Yes No

Do you have a congenital heart defect?

Yes No

Do you have a pacemaker, neurostimulator or ICD?

Yes No

Are you currently being monitored by the thrombosis services?

Yes No

Have you ever fainted during a dental or medical treatment?

Yes No

Do you suffer from hyperventilation?

Yes No

Do you suffer from epilepsy/falling disease?

Yes No

Have you ever had a brain haemorrhage, stroke or TIA?

Yes No

Do you suffer from lung complaints such as asthma, bronchitis or chronic cough?

Yes No

If so, are you short of breath?

Do you suffer from diabetes?

Yes No

If so, do you use insulin?

Do you suffer from anemia?

Yes No

Do you use something for this?

Have you ever suffered from extensive bleeding after tooth extraction, surgery or injuries?

Yes No

Do you have hepatitis, yellow fever or any other liver disease?

Yes No

Do you have any kidney diseases?

Yes No

Do you have chronic stomach complaints?

Yes No

Do you suffer from a thyroid disorder?

Yes No

Do you have rheumatism and/or chronic joint complaints?

Yes No

Have you ever used in the past medication for osteoporosis such as denosumab or bisphosphonate?

Yes No

If so, please specify

Do you have a contagious disease?

Yes No

If so, please specify

Have you ever received radio therapy for a tumour in head and/or neck?

Yes No

Do you smoke and/or use an e-smoker/vape?

Yes No

If so, how many a day?

Do you drink alcohol?

Yes No

For the women: are you pregnant?

Yes No

Do you use any medication?

Yes No

If so, what kind of medication do you use?

Do you have a disease or condition that has not been asked about?

Yes No

If so, which?

I have read and agree to the privacy policy.

Tandartsen praktijk de nieuwe gracht

Openingstijden:

maandag
08:00 - 17:00
dinsdag
08:00 - 17:00
woensdag
08:00 - 17:00
donderdag
08:00 - 17:00
vrijdag
08:00 - 17:00
zaterdag
Gesloten
zondag
Gesloten

Extra berichtgeving openingstijden

Adres:

Tandartsenpraktijk de Nieuwegracht
Nieuwegracht 79
3512LH Utrecht

Contact:

Telefoon: 030 - 2313130
info@tandartsenpraktijkdenieuwegracht.nl

Contact

Tandartsenpraktijk de Nieuwegracht
Nieuwegracht 79
3512LH Utrecht
Telefoon: 030 - 2313130
E-mail: info@tandartsenpraktijkdenieuwegracht.nl

Openingstijden

maandag08:00 - 17:00
dinsdag08:00 - 17:00
woensdag08:00 - 17:00
donderdag08:00 - 17:00
vrijdag08:00 - 17:00
zaterdagGesloten
zondagGesloten

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