Gender * —Kies een optie—ManWoman
Surname and initial(s) *
E-mail address *
Social Security Number *
Profession
General Practitioner *
1. Are you healthy and do you feel healthy? YESNO
2. Are you currently being treated by a general practitioner or medical specialist? YESNO
3. Have you been treated medically in the past year? YESNO
4. Is it necessary that you receive preventive antibiotic protection in the event of bloody procedures (for example, heart valve abnormalities or artificial hip)? YESNOI'm not sure
5. Have you ever been hospitalized? YESNO
6. Do you suffer (or have you suffered) from any of the following conditions? Congenital or acquired heart defectEpilepsyHeart murmurVenereal diseasesValve prosthesis/valve deficiency/pacemakerDiabetesEndocarditisFainting / passing outMyocardial infarctionJaundice / HepatitisAngina Pectoris (pressure on the chest during exercise)TuberculosisHigh blood pressure/low blood pressureLeukemiaKidney or liver diseaseThyroid disorderAcute RheumatismHave you ever had radiation treatment?Thrombosis/pulmonary embolismOsteoporosisStrokeAllergyFoul taste or breathHaemophilia (blood disease)AIDSAnemia
7. Do you use medicines? YESNO
8. Have you taken a course of antibiotics in the past 3 months? YESNO
9. Are you hypersensitive to one or more of the following substances? AnestheticAspirinIodineLatexPenicillins/Antibiotics
10. Are you currently checked by the Thrombosis Service? YESNO
11. Have you ever suffered from bleeding after tooth extraction, surgery or injuries? YESNO
12. Have you ever had an abnormal reaction to anesthesia? YESNO
13. Do you have implants or a transplant somewhere in the body? YESNO
14. Have you ever had blood taken and any details found? YESNO
15. Are you a blood donor? YESNO
16. Do you smoke? YESNO
If not, have you ever smoked? YESNO
17. Do you drink alcohol? YESNO
18. (Women) Are you pregnant? YESNO
19. Is there anything from your medical history that you would like to mention? YESNO
I give permission to add this medical statement to my dental file.
