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Medical history

Your health and medication can affect your oral health and dental treatment. In some cases, we may need to adjust your treatment or take additional precautions. We therefore ask you to complete the questions below as fully as possible.

Your medical information is subject to medical confidentiality and will be treated confidentially. More information about how we handle your personal data can be found in our privacy statement.

Personal details

Name *

Date of birth *

Gender *

Health questions

Has your health changed in the last few months? *

Are you allergic? *

Have you had a heart attack? *

Do you suffer from heart palpitations? *

Are you being treated for high blood pressure? *

Do you get chest pain on exertion? *

Are you short of breath when lying flat? *

Do you have a heart valve defect or an artificial valve? *

Do you have a congenital heart defect? *

Have you had endocarditis? *

Do you have a pacemaker/ICD or neurostimulator? *

Have you ever fainted during dental or medical treatment? *

Do you have epilepsy? *

Have you had a stroke, TIA or brain haemorrhage? *

Do you have lung issues (asthma, bronchitis, chronic cough)? *

Do you have diabetes? *

Do you have anaemia? *

Do you bleed for a long time after an extraction or surgery? *

Do you have hepatitis, jaundice or liver disease? *

Do you have kidney disease? *

Do you have rheumatism or chronic joint complaints? *

Have you been radiated for a tumour in the head/neck area? *

Do you smoke? *

Do you have another disease not asked about above? *

Have you previously used bisphosphonates or denosumab for osteoporosis? *

Do you take medication? *

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