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Medical History Questionnaire

We kindly ask you to complete the questionnaire below. Your information will be handled confidentially and in accordance with data protection laws. If your answers indicate the need, the oral surgeon may request additional information during your first visit.

1.Do you experience pain or a tight feeling in your chest during physical exertion? (Angi
Nee
Ja
2.Have you had a heart attack? Or do you have a heart murmur or a heart valve disorder?*
Nee
Ja
3.Do you have an artificial hip, knee, or heart valve?*
Nee
Ja
4. Have you undergone vascular surgery less than 6 months ago?*
Nee
Ja
5. Do you experience episodes of heart palpitations without physical exertion?*
Nee
Ja
6. Do you have heart failure?*
Nee
Ja
7. Do you have high blood pressure?*
Nee
Ja
8. Have you experienced paralysis (stroke, attack) or speech disorders?*
Nee
Ja
9. Have you ever fainted during a dental or other medical procedure?*
Nee
Ja
10. Are you currently taking any medications?*
Nee
Ja
11. Are you taking medication for epilepsy?*
Nee
Ja
12. Do you suffer from hyperventilation?*
Nee
Ja
13. Do you have asthma?*
Nee
Ja
14. Do you have a lung disease?*
Nee
Ja
15. Have you ever had an allergic reaction after using medications or medical materials?*
Nee
Ja
16. Do you have diabetes?*
Nee
Ja
17. Have you been diagnosed with a thyroid disorder?*
Nee
Ja
18. Have you (or have you had) hepatitis, jaundice, or another liver disease?*
Nee
Ja
19. Do you have a kidney disease?*
Nee
Ja
20. Do you have chronic stomach or intestinal complaints?*
Nee
Ja
21. Do you currently have a contagious disease? (For example, hepatitis, HIV, TB)*
Nee
Ja
22. Do you have anemia?*
Nee
Ja
23. Do you have a malignant disease of the lymph nodes or a blood disorder?*
Nee
Ja
24. Have you been diagnosed with a bleeding disorder?*
Nee
Ja
25.Have you received radiation therapy in the head/neck area?*
Nee
Ja
26. Do you have memory problems?*
Nee
Ja
27. Have you needed assistance with self-care in the past 24 hours?*
Nee
Ja
28. Have there been periods of confusion during a previous hospital stay or illness?*
Nee
Ja
29. Do you use bisphosphonates (bone resorption inhibitors) for conditions such as osteoporosis
Nee
Ja
31. Have you undergone any surgeries in the past?*
Nee
Ja
32. Do you smoke? *
Nee
Ja
33. Do you use drugs?*
Nee
Ja
34. Women: Are you pregnant?*
Nee
Ja
35. Do you have any illness or condition that is not mentioned in this questionnaire?*
Nee
Ja
36. Have you recently tested positive for MRSA/BRMO bacteria?*
Nee
Ja
37Have you been hospitalized in the past two months in Holland during an MRSA or BRMO outbreak?*
-
Nee
Ja
38. Have you stayed in a foreign healthcare facility in the past two months with surgery/infection
-
Nee
Ja
39. Have you had contact with farmed pigs, veal calves, or chickens, or do you live on such a farm?*
-
Nee
Ja
40. Do you currently live or have you lived in an asylum seekers' center in the past two months?*
-
Nee
Ja
Overons team omar kaakchirurgie holland

More information about a treatment?

For more information, feel free to contact us or visit a location near you.

- Omar Badarne

Contact us

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