Skip to content

No waiting time
Google Rating: 4.9 out of 5.0 (110+ reviews)

NL

Register

+31 (0)36 203 08 39

Pre-operative questionnaire

Personal data

First name

Last name

Date of birth

Age

Address

Email Address

Phone number

Weight

Height

Blood Pressure

BMI

How did you come to us

Additional data

Name general practitioner

Phone number general practitioner

Name pharmacy

Phone number pharmacy

Name companion

Phone number companion

1. Are you allergic to anything, and how does it manifest?

Latex/rubber/adhesive plasters

Itching Rash Hives Swelling

Dust mites / house dust

Itching Rash Hives Swelling

Anesthetics at the dentist

Itching Rash Hives Swelling

Plants / pollen / trees

Itching Rash Hives Swelling

Disinfectants / iodine

Itching Rash Hives Swelling

Medication

Itching Rash Hives Swelling

Food

Itching Rash Hives Swelling

2. Check what applies and provide an explanation

I drink more than 2 glasses of alcohol per day

I smoke a number of cigarettes per day

I use drugs or have done so

I use medication (including birth control, sleeping pills, alternative medication,etc.)

I have undergone surgery before

3. Check what applies and give explanation

I experience cramping chest pain during exertion

I have palpitations or an irregular heartbeat?

I am under treatment for high blood pressure

I have swollen feet or ankles in the evening

I can easily walk up two flights of stairs

I feel breathless when lying flat

I suffer from chronic coughing

I have asthma or bronchitis

I am under treatment or being monitored for tuberculosis

I often feel dizzy

I have had a stroke or partial paralysis

I experience fainting spells

I have epilepsy

I have a muscle disease

I have diabetes mellitus (diabetes)

In the past week, I have used a painkiller

I bleed for a long time after injuries or tooth extractions

I bruise easily after bumps or falls

I have had a blood clot in the leg or lungs

I am under the care of the anticoagulation service

I am being treated or monitored for a thyroid disorder

I have stomach complaints or acid reflux

I have had jaundice in the past five years

I have a kidney disease

I have joint pain or rheumatic complaints

I am familiar with breathing problems during my sleep

I am pregnant

I am breastfeeding

I find it difficult to bend my head far backward

I find it difficult to open my mouth wide

I have loose teeth and/or molars

I wear contact lenses

I have piercings

I have had a blood transfusion before

I have been treated by a specialist

I belong to the risk group for AIDS or hepatitis B

I have other physical complaints besides my teeth

There are other details about my health or lifestyle that may be relevant to the anesthesiologist

I object to a blood transfusion, blood sampling, or the use of blood products during treatment (only applied in extreme necessity)

I have been abroad in the past year

I have been treated in a healthcare institution with MRSA issues (hospital bacteria) in the past two months

I work or live on a farm with live pigs, veal calves, and/or broilers

I have a partner, roommate, or someone else who is MRSA positive

I am a carrier of MRSA or carry another resistant bacterium

I will be picked up by someone on the day of the treatment

There is someone at home after the treatment who can take care of me

I am aware of and agree with the nature and purpose of the treatment and anesthesia

Details of the primary contact person

I consent to my escort being informed about what happened during the treatment

Questions

Privacy policy

I agree to the processing of my personal data in accordance with the privacy policy.

Schoutstraat 120
1315 EZ Almere
+31 (0)36 203 08 39
info@narcosedental.nl

Facebook Instagram

Opening hours

Monday
Tuesday
Wednesday
Thursday
Friday

08:30 - 17:00
08:30 - 20:00
08:30 - 20:00
08:30 - 17:00
08:30 - 17:00

Navigation

Homepagina
Register now
First appointment
Vacatures
Contact

Our practice is sometimes open in the evening for appointments.
Call us and ask about the possibilities.

Home

Register

Call us

Homepage
About us
Treatments
Patiënt information
Register
Referrals
Contact

Facebook Instagram