New patient | Dental220

Surname: *

First name: *

Gender: *

Male

Female

Address:

Zipcode + City: *

Email: *

Private phone nr.:

Work phone nr.:

Birth date: *

BSN/social security nr.: *

Insurance Company: *

Insurance nr.: *

General questions

How did you find us?:

What do you expect from us?:

Would you like reminders by email/SMS:

Yes

No

Dental questions

Are you afraid of the dentist?:

Yes

No

Sometimes

When did you last visit a dentist?:

Were your visits regular?:

Yes

No

Almost

Please bring your dental records from your old dentist.

What is the current state of your teeth?:

Good

Not bad

Bad

Are you satisfied with the look of your teeth?:

Yes

No

Do you have any dental issues at the moment:

Yes

No

If so, which ones:

How often do you brush your teeth?:

Do you use any floss or toothpicks?:

Yes

Sometimes

No

How often do you use floss or toothpicks?:

Have you ever visited a dental hygienist?:

Yes

No

Would you like to visit a dental hygienist?:

Yes

No

Maybe

Medical questions

Are you in good health?:

Yes

No

Do you have any allergies?:

Yes

No

If so, what allergies do you have?:

Do you use any medication?

Yes

No

If so, what medication do you use:

Have you ever had any complications during or after dental treatment?:

Yes

No

Have you been admitted to a hospital or have you seen a medical specialist in the last 5 years?:

Yes

No

Do you have any form of hart disease?:

Yes

No

Do you have a hart condition that requires antibiotics for any dental/medical treatment?:

Yes

No

Do you have an artificial heart valve

Yes

No

Do you have high blood pressure?:

Yes

No

Do your blood clot normally? Do you suffer from haemophilia?:

Yes

No

Do you have any form of lung disease?:

Yes

No

Heeft u astma of andere ademhalingsproblemen?

Yes

No

Do you have hay fever?:

Yes

No

Do you have rheumatoid arthritis?:

Yes

No

Do you have any implants in your body (artificial hip joints, hart valves etc)?:

Yes

No

Do you have epilepsy?:

Yes

No

Are you diabetic?:

Yes

No

Do you have any other transmittable diseases?:

Yes

No

Do you have adequate liver and kidney function?:

Yes

No