Medical History Name:(Vereist)Why is a health questionnaire important for your dentist and dental hygienist? Complaints in the mouth can be caused by illness or medication use. If you are ill or take medication, this may limit dental treatment or require precautionary measures. It is important that your dentist takes this into account. Always inform your dentist if anything has changed in your health or medication use. Your data is covered by medical confidentiality and will therefore be treated confidentially. Bring a recent medication list with you to every visit to your dentist. You can request a recent list from your pharmacist.Gender:(Vereist) Female Male Date of birth:(Vereist) DD slash MM slash JJJJ Has anything changed in your health in the past few months?(Vereist) Yes No If yes, what?Have you ever had a heart attack?(Vereist) Yes No If yes, when?Are you allergic to anything?(Vereist) Yes No If yes, what?Do you suffer from palpitations?(Vereist) Yes No Are you being treated for high blood pressure?(Vereist) Yes No Lower pressure:Upper pressure:Do you have chest pain during exertion?(Vereist) Yes No Do you become short of breath when lying flat in bed?(Vereist) Yes No Do you have a heart valve defect or an artificial heart valve?(Vereist) Yes No Do you have a congenital heart defect?(Vereist) Yes No Have you ever had endocarditis?(Vereist) Yes No Do you have a pacemaker (or ICD) or neurostimulator?(Vereist) Yes No Have you ever fainted during dental or medical treatment?(Vereist) Yes No Do you have epilepsy?(Vereist) Yes No Have you ever had a cerebral hemorrhage, stroke, or TIA?(Vereist) Yes No Do you have lung problems such as asthma, bronchitis, or chronic cough?(Vereist) Yes No Do you have diabetes?(Vereist) Yes No If yes, do you use insulin?Do you have anemia?(Vereist) Yes No Have you ever had prolonged bleeding after having teeth removed or after surgery?(Vereist) Yes No Have you had hepatitis, jaundice, or another liver disease?(Vereist) Yes No Do you have kidney disease?(Vereist) Yes No Do you have rheumatism and/or chronic joint problems?(Vereist) Yes No Have you been irradiated because of a tumor in the head or neck?(Vereist) Yes No Do you smoke?(Vereist) Yes No If yes, how many per day?Are you pregnant?(Vereist) Yes No Are you breastfeeding?(Vereist) Yes No Do you have a disease or condition that has not been asked about?(Vereist) Yes No If yes, which one?Have you ever used a medicine for osteoporosis, such as a bisphosphonate or denosumab?(Vereist) Yes No If yes, which one?Do you take medication?(Vereist) Yes No If yes, which one?Current date:(Vereist) JJJJ dash MM dash DD Privacy policy(Vereist) I agreeSignature(Vereist)
