Health questionnaire

Why is a health questionnaire important for your dentist and dental hygienist?

  • Problems in the mouth can be caused by illness or medication
  • Some diseases or medication may be a limitation for dental treatments or in some cases we need to take precautionary measures. It is important that your dentist takes this into account.
  • Always inform your dentist if something has changed in your health or your medication. Your data falls under medical professional secrecy and are therefore treated confidentially.
  • Take a recent medication overview to every appointment with your dentist. You can ask this overview to your pharmacist. 

    Has anything changed in your health in the last months?

    Are you allergic to something?

    Did you have a heart attack in the past?

    Do you suffer from palpitations?
    Do you get treatments for high blood pressure?

    If yes, what is your blood pressure?

    Do you have chest pain during exercise?
    Do you suffer from short breath when you lie flat?
    Do you have a heart valve defect or an artificial heart valve?
    Do you have a congenital heart defect?
    Have you ever had an endocarditis?
    Do you have a pacemaker (or ICD) or a neurostimulator?
    Have you ever fainted at a dental or medical treatment?
    Do you have epilepsy, falling illness?
    Did you ever had a cerebral haemorrhage or stroke (TIA)?
    Do you suffer from lung complaints such as asthma, bronchitis or chronic cough?
    Do you have diabetes?

    Do you have anemia?
    Have you ever had prolonged bleeding after extraction of teeth or surgery?
    Do you have hepatitis, jaundice or other liver disease (or have you had)?
    Do you have a kidney disease?
    Do you have rheumatism and/or chronical joint complaints?
    Have you been irradiated due to a tumor in the head or neck?
    Do you smoke?

    Are you a woman


    Do you have a disease or condition that is not been asked in this questionnaire?

    Have you used medicine in the past against bone loss (a bisphosphonate or denosumab)?

    Do you use medicine?