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Personal information

Initials *
Nickname
last name *
Date of birth
Sex
Adress
Zip code
Place
phone (mobile) *
phone (home)
e-mail address *
Profession
Are you insured for dental procedures?
Social Security Number *
Insurance company
Insurance registration number

CARE INFO

Who is your doctor?
Have you been to the dentist regularly in recent years?
Who was your previous dentist?
Where was your previous dentist?
Are you satisfied with the position of your teeth?
Are you satisfied with the color of your teeth?
Are you currently having problems with your teeth?
Are there things we should take into account?

Your health

Has anything changed in your health in recent months? *
if not, please put "no" in the field
Are you allergic to anything? *
if not, please put "no" in the field
Did you have a heart attack? *
Do you suffer from palpitations? *
Do you have chest pain with exertion and/or emotions? *
Do you get short of breath when you lie in bed? *
Are you being treated for high blood pressure? *
Do you have a congenital heart defect? *
Have you ever experienced endocarditis? *
Do you have a heart valve deficiency or an artificial heart valve? *
Have you ever passed out during dental or medical treatment? *
Do you have epilepsy/falling sickness? *
Do you have a pacemaker (or ICD) or neurostimulator? *
Do you suffer from lung diseases such as asthma bronchitis or chronic cough? *
Do you have diabetes? *
Have you ever had a brain haemorrhage or stroke (TIA)? *
Are you currently having problems with your teeth? *
Have you ever had prolonged bleeding after a tooth extraction or after an operation or injury? *
Do you use insulin? *
Do you have anemia? *
Do you have rheumatism and/or chronic joint complaints? *
Do you have (or have had) hepatitis, jaundice or other liver disease? *
Do you have kidney disease? *
Are you pregnant? *
Have you been irradiated for a tumor in the head and/or neck? *
Do you smoke? *
Do you have a disease or condition that has not yet been asked? *
if not, please put "no" in the field
Are you breastfeeding? *
Have you used a medicine against osteoporosis (a bisphosphonate or denosumab) in the past? *
Are you currently taking any medications? *
if not, please put "no" in the field

Remarks

How did you come to us?
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