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030 252 03 59 info@dentalcareutrecht.nl Spoed avond/weekend 0900 1515

Medical history

Name: Dental Care Utrecht
Address: Van Hogendorpstraat 1, Utrecht, 3581 KA, NL
Telephone: 030 252 03 59

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 Dental Care Utrecht"

My Website

Name

Date of birth

E-mail

Gender

Male

Female

Today's date

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

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 have palpitations?

Yes No

Are you receiving treatment 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 at the dentist or during a medical examination?

Yes No

Do you suffer from hyperventilation?

Yes No

Do you suffer from epilepsy/falling disease?

Yes No

Have you ever suffered a cerebral haemorrhage or a 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 have diabetes?

Yes No

If so, do you insulin?

Do you have anemia?

Yes No

Have you ever had prolonged bleeding after pulling your teeth?

Yes No

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

Yes No

Do you have kidney disease?

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

Do you have an artificial joint?

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 per day?

Do you use drugs?

Yes No

If so, please specify

Do you drink alcohol?

Yes No

If so, how many glasses per week?

Women: Are you pregnant?

Yes No

Do you use medication?

Yes no

If so, please specify

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

Yes No

If so, please specify

I have read and agree to the privacy policy.

Locaties

Dental Care Utrecht VH

Van Hogendorpstraat 1
3581 KA Utrecht

Dental Care Utrecht WB

Willem Barentszstraat 1
3572 PA Utrecht

Dental Care Utrecht WP

Wilhelminapark 26
3581 NE Utrecht

Dental Care Maliebaan

Maliebaan 63
3581 CE Utrecht

Tandartspraktijk de Nieuwegracht

Nieuwegracht 79
3512 LH Utrecht

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
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zondag
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's Avonds en in het weekend kunt u bellen naar de 24-uurs spoeddienst van de Mondzorg Poli Utrecht op 0900 1515.

Onze diensten

Voor overige behandelingen verwijzen we u graag naar onze behandelingspagina's:

Tandenbleekservice
Endodontologie
Facings plaatsen
Implantologie
Kronen & Bruggen plaatsen
Mondhygiëne
Gnathologie
Orthodontie (Beugels)
Parodontologie
Preventieve gebitscontroles
Prothetiek
Kaakfysiotherapie

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