Before your first appointment

Health questionnaire for adults

Welcome to Tandarts West, your English-speaking dentist in Rotterdam West at Taandersstraat. To provide safe, personalised care, we ask you to complete this short health questionnaire (anamnesis). It takes about 5 minutes. Your details are stored securely and GDPR-compliant.

Your answers are confidential. They are sent over a secure connection and only seen by your treating dentist. Prefer to fill it in on paper? Click "Print or save as PDF" below and bring the completed form with you to your appointment.

Personal details

Who are you? We need this for your patient file and billing.

9 digits, found on your Dutch ID or residence permit

GP and health insurance

For referrals and billing through Infomedics.

General health

Answer yes / no. If yes: provide details in the comments field at the bottom.

Heart and blood vessels

Important for anaesthesia and any prophylactic antibiotics.

Recently measured, by GP, home monitor or pharmacy.
Only fill in if you ticked "heart attack" above.

Other conditions

Tick what applies. If in doubt: tick the box and explain in the comments.

Medication and allergies

Please list all medication (including over-the-counter) and known allergies.

Mouth and dental history

So we can prepare your first appointment well.

Frequently asked question

Frequently asked question about the health questionnaire

Can you go to the dentist while taking blood thinners?
Yes, you can be treated as normal if you take blood thinners. Always list your medication on this health questionnaire. For most treatments you do not need to stop; for a procedure such as extracting a tooth the dentist will, if needed, consult your doctor or the thrombosis service. Never stop on your own without consultation.