Health
Declaration

We kindly request you to complete the questionnaire below. It is essential to both, you and us, that the dentist is fully informed about your health condition. The answers will be treated discreetly as we abide by the duty of medical confidentiality.

Your oral health can be (strongly) influenced by several diseases and the use of certain medications. Therefore, your dentist must take this into account when devising an appropriate treatment plan.

Should you have any problems completing this Health Declaration questionnaire, you have the option to complete it together with the care consultant at the clinic before the intake interview. Please let us know in time to plan this and send your e-mail request to: info@denteamclinics.nl

    Health Declaration

    Your e-mail
    Name of emergency contact*
    Emergency contact phone number*
    The first two questions relate to calculating your BMI (Body Mass Index). The BMI provides an estimate of the health risk of your weight. We need this information if, for example, you will have treatment under anesthesia.
    What is your hight? (cm)*
    What is your weight? (kg)*
    Do you have any allergies?*
    If yes, what allergy/allergies?
    Have you suffered a heart attack?*
    Do you suffer from heart palpitation?*
    Are you being treated for high blood pressure?*
    Do you have chest pain during exertion or exercises?*
    Are you short of breath when lying on your bed?*
    Do you have a congenital heart condition?*
    Do you have a pacemaker (or ICD) or neurostimulator?*
    Have you ever fainted during dental or medical treatment?*
    Do you suffer from epilepsy?*
    Have you had a stroke (or TIA)?*
    Do you suffer from coughing comlaints such as asthma, bronchitis, or chronic cough?*
    Are you diabetic?*
    Are you anemic?*
    Have you ever sustained prolonged bleeding after tooth extraction of surgery?*
    Do you take blood thineers (anticoagulants)?*
    Have you ever had hepatitis, jaundice, or any other liver disease?*
    Do you have kidney disease?*
    Do you have rheumatism and/or chronic joint complaints?*
    Do you have an artificial joint?*
    Do you smoke?*
    If yes, how many cigarettes on average day?
    Do you consume alcohol?*
    If yes, how many glasses of alcohol on average per day?
    Do you have any other disease or condition that was not mentioned above?*
    If yes, what disease/condition?
    Are you on any medications?*
    If yes, which medications?
    Have you suffered from Covid-19 (Corona) in the last six months?*
    Date Health Declaration*
    By answering the above questions, you declare that you have answered all questions truthfully. It is essential to both you and us that your dentist is fully aware of your health condition. These answers are subject to medical confidentiality. Yes, I declare that I have answered all questions truthfully.

    Want us to call you?

      Plan your
      INTAKE

      Any questions?