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Medical history questionnaire

We have filled out the questionnaire below for you to fill in. Your data will be processed discreetly and according to the wet personal data. If answers give reason to do so, your practitioner will ask you for sufficient additional information during your first visit.

Are you a patient in Capelle or Rotterdam?
Capelle aan den IJssel
Rotterdam
1. Do you have pain or a tight feeling in your chest during exertion? (Angina Pectoris)
Nee
Ja
2.Have you had a heart valve defect/heart attack/heart failure/heart murmur?
Nee
ja
3. Do you have an artificial hip, knee or heart valve?
Nee
Ja
4. Have you had vascular surgery less than 6 months ago?
Nee
Ja
5. Do you have attacks of heart palpitations without exertion?
Nee
Ja
6. Do you have high blood pressure?
Nee
Ja
7. Have you had any paralysis (stroke, seizure) or speech disorders?
Nee
Ja
8. Have you ever fainted during dental or other medical treatment?
Nee
Ja
9. Are you taking medication for epilepsy?
Nee
Ja
10. Do you suffer from hyperventilation?
Nee
Ja
11. Do you have a lung disease/asthma?
Nee
Ja
12. Have you ever had an allergic reaction after using medicines or medical supplies?
Nee
Ja
13. Do you have diabetes? If so, do you use insulin?
Nee
Ja
14. Have you been diagnosed with a thyroid disorder?
Nee
Ja
15. Do you have (or have you had) hepatitis, jaundice or another liver disease?
Nee
Ja
16. Do you have kidney disease?
Nee
Ja
17. Do you have chronic stomach/intestinal complaints?
Nee
Ja
18. Do you currently have a contagious disease? (For example hepatitis, HIV, tuberculosis)
Nee
Ja
19. Do you have anemia?
Nee
Ja
20.Do you have a malignant disease of the lymph nodes or a blood disorder?
Nee
Ja
21.Have you been diagnosed with a bleeding tendency?
Nee
Ja
22. Have you had radiation treatment in the head/neck area?
Nee
Ja
23. Are you having memory problems?
Nee
Ja
24. Did you need help with self-care in the past 24 hours?
Nee
Ja
25. Have there been periods of confusion during a previous hospitalization or illness?
Nee
Ja
26. Are you using Bisphosphonates (bone breakdown inhibitors)?
Nee
Ja
27. Are you using medicines at the moment?
Nee
Ja
28. Have you had any surgeries in the past?
Nee
Ja
29. Do you use drugs?
Nee
Ja
30. Do you smoke?
Nee
Ja
31. Are you pregnant?
Nee
Ja
32. Do you have a disease or an ailment which not is mentioned in this list of questions?
Nee
Ja
33. Have you recently tested positive for MRSA/BRMO bacteria?
Nee
Ja
34. Have you been admitted to a Dutch hospital in the past two months where you were in a department
Ja
Nee
35. Have you stayed in a foreign healthcare institution in the past two months? If so, do any of the
Ja
Nee
36. Have you had contact with commercially kept live pigs/veal calves/broiler chickens (regardless o
Ja
Nee
37.Do you live or have you lived in an asylum seekers' institution in the past two months?*
Ja
Nee
39. Do you give permission to send and receive your data that is necessary?
Ja
Nee
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