A patient-administered Medical Risk Related History

questionnaire (EMRRH) for use in 10 European countries

(multicenter trial)
Luzi Abraham-Inpijn, MD, PhDa, Gordon Russell, MB.FDSRCSb, Didi A. Abraham, MScc,
Nils Bäckman, DDSd, Erika Baum, MD, PhDe, Philip Bullón-Fernández, DDS, PhD, MDf,
Dominique Declerck, DDS, PhDg, Jean-Christophe Fricain, DDS, PhDh,
Marie Georgelin, DDSi, Karl O. Karlsson, DDSj,
Philip J. Lamey, BSc, BDS, MBChB, DDS, FDS, RCPS, FFD, RCSIk,
Iris Link-Tsatsouli, MD, PhDl, Orsolya Rigo, DDSm Amsterdam, The Netherlands, Cork,
Ireland, Nijmegen, The Netherlands, Umea, Sweden, Marburg, Germany, Sevilla, Spain,
Leuven, Belgium, Bordeaux II, France, Reykjavik, Iceland, Belfast, N. Ireland, Thessaloniki,
Greece, and Budapest, Hungary
ACADEMIC MEDICAL CENTRE, UNIVERSITY COLLEGE CORK, UNIVERSITY NIJMEGEN, NATIONAL
BOARD OF HEALTH AND WELFARE, KLINIKUM PHILIPPS, UNIVERSIDAD DE SEVILLA, CATHOLIC
UNIVERSITY LEUVEN, UNIVERSITÉ VICTOR SEGALEN, FACULTY OF DENTISTRY REYKJAVIK,
DEPARTMENT OF ORAL MEDICINE BELFAST, UNIVERSITY OF THESSALONIKI, AND SEMMELWEIS
UNIVERSITY

Objective. The objective of this study was to produce a standardized medical risk-related history (MRRH) in order to
identify the medically compromised patient (MCP) attending the general dental practitioner for treatment, to develop
such a history (EMRRH), and to validate it in dental practices in 10 European countries.
Study design. The Dutch MRRH, adapted to allow for legal and cultural differences of the participating countries was
introduced. After consensus and repeated testing, the questionnaire was validated. In this last phase, 1000 patients
older than 18 attending dental practices were selected, 100 per country; 994 medical histories were suitable for
statistical analysis. Validation was carried out by a physician accustomed to making preoperative assessments,
including the ASA risk classification.
Results. Mean specificity per country was 99.1 and per EMRRH item was 99.0. Mean sensitivity per country was 93.2
and per item was 93.7. Cohen’s kappa for the countries involved was 0.81 to 0.98 and for subsequent questions was
0.81 to 0.97.
Conclusion. The EMRRH was found to be valid in the detection of medically compromised patients in 10 European
countries. (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008;105:597-605)

The continuing increase in life expectancy has added to

The project organizers express their appreciation for the grant from
the Aja Ramakers Koning Foundation. Financial support was pro-
vided by Stichting Aja Ramakers Koning, Amsterdam, the Nether-
lands.
a
Emeritus Professor, Department of Internal Medicine, Academic
Medical Centre, University of Amsterdam, The Netherlands.
b
Emeritus Professor of Dental Surgery, University College, Cork,
Ireland.
c
Staff member, Department of Preventive and Community Dentistry,
College of Dental Science, University Nijmegen, The Netherlands.
d
Staff member, National Board of Health and Welfare, Umea, Sweden.
e l
Staff member, Klinikum Philipps, Marburg, Germany.
f
Professor and Chairman, Catedratico de Estomatologia, Facultad de
Odontologia, Universidad de Sevilla, Spain.
g
Staff member, Department of Preventive Dentistry and Special Care
Dentistry, Catholic University Leuven, Belgium.
h
Professor and Chairman, Faculté d’Ontologie, Université Victor
Segalen, Bordeaux II, France.
i
Staff member, Faculté d’Ontologie, Université Victor Segalen, Bor-
deaux II, France.
the number of ageing patients at medical risk during
dental treatment.1 Previous reports confirm that medi-
cal emergencies do occur in medically compromised
patients attending general dental practice.2-7 Since no
patient should leave the dental office in worse physical
j
Staff member, Faculty of Dentistry, University of Iceland, Reykja-
vik, Iceland.
k
Professor and Chairman, Department of Oral Medicine, Queen’s
University, Belfast, N. Ireland.
Staff member, Department of Oral Medicine and Oral Pathology,
University of Thessaloniki, Greece.
m
Staff member, Dental Faculty, Semmelweis University, Budapest,
Hungary.
Received for publication Aug 18, 2006; returned for revision Aug 11,
2007; accepted for publication Sep 28, 2007.
1079-2104/$ - see front matter
© 2008 Mosby, Inc. All rights reserved.
doi:10.1016/j.tripleo.2007.09.032

597

598 Abraham-Inpijn et al.
condition than when the patient came in, it is the
responsibility of the dentist to acquire the skills neces-
sary to identify patients with medical problems that
would put them at risk during dental treatment. The
participating academic medical and dental centers were
concerned that in some countries, not only in Europe,
dentists may not be sufficiently trained to detect and
manage such medical problems.8-11 A preventive in-
strument is needed to ensure the medical safety of
patients in dental practices in Europe. This patient-
administered European Medical Risk Related History
(EMRRH; provided at the end of this article) was de-
signed to register medical pathology that can interfere
with dental treatment, to indicate the degree of medical
risk involved, and to recommend measures to be taken by
the physician and/or the dental practitioner.12-15
Such an instrument, the Medical Risk Related His-
tory (MRRH-98), was part of an inventory study in the
Netherlands. Over a period of 1 year, the number of
medical calamities were recorded in 2 types of general
dental practices. One type used the MRRH-98 system
(reference group), while the control group made use of
various other kinds of history-taking methods. Calam-
ities due to medical problems dealt were found only in
the control group.7
This article reports on the prevalence of medical
problems in European countries, the need for a ques-
tionnaire such as the Medical Risk-Related History
(adjusted to meet local ethical and legal norms), and its
validation in the participating countries. The results of
this study across 10 European countries are presented
here.
METHODS
Dentists and patients
Medical and dental experts in 10 European countries
agreed to undertake the preliminary work, such as
detailing the legal and ethical norms of medical history
taking in their own country, and researching the prev-
alence of diseases that could interfere with dental treat-
ment.
These experts were asked to instruct cooperating
general practitioners in the use of the EMRRH. Both
the dentists and their patients were provided with writ-
ten instructions in the appropriate language, outlining
the reasons behind the EMRRH and how it was to be
used.
In each country the respondents consisted of 100
individuals, all of them patients who had come in for
dental treatment. Only those older than 18 were asked
to participate, in accordance with the terms of the
Declaration of Helsinki. The study was approved by the
medical ethics committee of the University of Amster-
dam and marginally tested by the participating centers.
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May 2008
Table I. The modified ASA physical classification sys-
tem for dentistry12
Class Physical status Therapy modifications
I Healthy patient None
II Patient with mild to moderate Possible stress reduction and
systemic disease not other modification as
interfering with daily life indicated
III Patient with severe systemic Possible strict modifications;
disease that limits activity stress reduction and
but is not incapacitating medical consultation are
priorities
IV Patient with severe systemic Minimal emergency care in
disease that limits activity office; hospitalize for
and is a constant threat to stressful elective treatment;
life medical consultation urged
V Moribund patient not Treatment in the hospital is
expected to survive 24 limited to life support only
hours with or without an
operation
Each center followed the terms of the Declaration of
Helsinki and in addition evaluated the EMRRH in the
local cultural and legal context. All legal and cultural
aspects were taken in to account resulting in an
EMRRH acceptable to all participating centers and
countries. Written informed consent, which covered all
information provided to the dentist and to the partici-
pating institutes, was obtained before accepting respon-
dents into the study. It was made clear to patients that
declining to participate in the study would not affect
their dental treatment. A power analysis of a pilot study
was used to determine the group sizes.
Questionnaire
Following an inventory study of calamities in the
dental chair, which was carried out in the Netherlands,
the MRRH-98 was upgraded and adjusted to meet the
legal and ethical norms in the participating countries.
That EMRRH questionnaire included the ASA risk-
score system developed by the American Society of
Anesthesiologists in the early 1940s to assess the risk
that general anesthesia poses to patients.16,17 That sys-
tem was modified to assess the risk to patients of dental
treatment carried out under local anesthesia (Table I).18
The questionnaire consists of a number of “yes or
no” questions designed to detect diseases of the cardio-
vascular system, the pulmonary system, and so forth.
The main questions are in bold type. A negative reply
to the main question signifies that the patient is not
suffering from this type of disease or condition, and is
recorded as ASA risk I. A positive reply is recorded as
an ASA II risk and alerts the dentist to the presence of
disease. Each main question is followed by 2 or more
subquestions printed in standard type. These subques-
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Volume 105, Number 5 Abraham-Inpijn et al. 599

Table II. An example of the application of the ASA Table III. Characteristics of the patients in the partic-
classification in the European Medical Risk Related ipating countries
History Mean age of Age range,
Question Yes No ASA score* Country % Male patients, y y
Do you experience chest pain upon 0 0 II Belgium 62 51.4 18-78
exertion (angina pectoris)? If so, France 54 45.3 18-82
Are your activities restricted? 0 0 III Germany 45 43.3 18-79
Have the complaints increased recently? 0 0 IV Greece 36 57.7 18-83
Do you have chest pain at rest? 0 0 IV Hungary 36 46.0 19-81
Iceland 43 49.1 19-86
Positive response; ASA II; patients answer the subquestions. Ireland 22 57.0 21-83
Positive response to 1 or more subquestions places patient in ASA III Spain 32 51.9 18-83
or IV. Sweden 43 66.5 55-83
*Each item is subdivided into a main or bold question and one or The Netherlands 45 41.0 19-76
more subquestions. Negative response; ASA I; patients disregard the
subquestions.

tions are answered only when the main question is RESULTS

answered positively.
The subquestions are graded to indicate the increas-
ing severity of the disease. A positive answer to the first
subquestion of a principal question gives rise to a score
of ASA III and subsequent positive replies to subques-
tions of the same principal question result in a score of
ASA IV. Therapy modifications are suggested for each
rating of II or higher. Scores of ASA III and IV include
a recommendation to seek medical consultation. The
ASA V category is not included in the EMRRH, as a
patient in this condition would be too ill to visit a dental
practice. Scoring is not cumulative. Table II contains
an example of the ASA scoring of a question of the
EMRRH.
Registration and statistics
All the participating centers followed the standard-
ized procedure described in 1992 and 1997.12,20 Each
patient was asked to complete the EMRRH question-
naire. Afterwards the answers were checked by the
dentist in order to ensure that there were no errors or
omissions. At a second session the patient met with a
physician experienced in pre-assessment control, who
took a traditional verbal medical history and who re-
corded his or her findings. A third independent re-
searcher compared the 2 forms for each patient, the
patient-administered questionnaire and the recorded
verbal history. In this comparison the findings of the
pre-assessment physician were taken as the ”gold stan-
dard.”
Both the sensitivity and the specificity of the ques-
tionnaire were assessed, per country and per EMRRH
item. Cohen’s kappa, a measure of agreement between
observers that includes an adjustment for chance agree-
ment, was likewise calculated. Additional comments
made by the participating general practitioners were
summarized.
Dentists and patients
An overview of the countries involved, the number
of patients in each country, and their gender is found in
Table III. The patient population was 41.8% male and
58.2% female. The mean age was 50.9 years (range 18
to 86).
Of the participating dentists, 78% were very satisfied
with the results because a great deal of information had
been obtained in a relatively short time. Patients
seemed to appreciate the dentist’s concern for their
general health.
Questionnaire
Of the 1000 pairs of questionnaires (the patient-
administered questionnaire and the recorded verbal his-
tory), a total of 995 medical histories were available for
statistical analysis. According to a power analysis, the
patient population consisting of 994 patients was ac-
ceptable for statistical purposes.
On the basis of the results of an inquiry among
participating dentists, the patient-administered ques-
tionnaire proved to be easy to use in the general dental
practice. Because it is standardized, it takes only 2
minutes to administer in the case of a healthy individual
and no more than 10 minutes in the case of a patient
with reading difficulties and/or complicated health
problems.
Registration and statistics
No relation was found between the prevalence of
systemic diseases and the mean age per country. In the
10 countries represented, the overall prevalence of dis-
ease entities within the dental population studied, ex-
pressed as percentages, varied from 0.07 (The Nether-
lands) to 0.19 (Spain). The mean prevalence per disease
varied from 0.02 for epilepsy and kidney disease to
0.27 for hypertension. The prevalence per item was
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600 Abraham-Inpijn et al. May 2008

Table IV. Results per disease in the participating countries*

False False
Question negative positive Sensitivity Specificity Prevalence
1. Angina pectoris 4 8 96 99 0.11
2. Myocardial infarction 3 2 93 100 0.06
3. Heart murmurs 3 4 97 99 0.07
4. Heart palpitations 9 12 94 99 0.14
5. Heart failure 7 3 95 99 0.06
6. Hypertension 31 18 85 97 0.27
7. Bleeding tendency 5 9 91 99 0.05
8. Epilepsy 0 1 100 100 0.02
9. Asthma 1 6 98 99 0.09
10. Lung disease 4 7 90 99 0.10
11. Allergy 19 19 85 98 0.21
12. Diabetes mellitus 3 4 97 100 0.08
13. Thyroid condition 4 1 92 100 0.07
14. Liver disease 8 2 89 100 0.03
15. Kidney disease 2 2 94 100 0.02
16. Malignancies 2 8 99 99 0.04
17. Infectious disease 3 1 92 100 0.02
18. Hyperventilation 2 6 97 98 0.10
19. Fainting 1 5 95 99 0.06
20. Antibiotics 5 8 94 98 0.10
21. Medication 23 7 95 98 0.54
*Number of questions for each disease is 995 except for infectious disease and antibiotics (n ⫽ 783); for hyperventilation and fainting (n ⫽ 789).

highest for medication at 0.54 (range 0.39 to 0.86). A DISCUSSION

review of the results, including the false-positive and
negative, answers is found in Tables IV and V.
The mean specificity of the EMRRH per country,
expressed as percentage, was 99.1 (range 98 to 100).
Because fainting, hyperventilation, and the need for
antibiotic prophylaxis before dental treatment are not
part of the original ASA risk assessment for general
anesthesia; these items were not included in the pre-
assessment interview in France, Sweden, and Northern
Ireland. When these 3 countries were included, the
mean percentage was 99.0. The mean specificity per
item was 99.0 (range 97 to 100), regardless of inclusion
or exclusion of the above items.
The mean sensitivity of the EMRRH per country,
expressed as percentage, was 93.5 (range 87 to 98)
when the 3 countries mentioned were excluded, and
93.2 (range 85 to 98) with inclusion of these countries.
Mean sensitivity per disease expressed as percentage
was 93.5 (range 85 to 100) when infections, hyperven-
tilation, fainting, and antibiotic prophylaxis were ex-
cluded. When these 4 items were included, the percent-
age was 93.7 and the range was 85 to 100.
Cohen’s kappa per country ranged from 0.81
(France) to 0.98 (Spain). Per item, the Cohen’s kappa
ranged from 0.79 for liver disease to 0.97 for epilepsy
(Table VI).
Table VII shows the distribution of the ASA
scores and the mean age of patients in the countries
involved.
An essential element in this study was the proper
clinical evaluation of the EMRRH questionnaire. The
verbal history is considered the gold standard since the
physicians administering the verbal medical history are
accustomed to conducting preoperative assessments,
setting the ASA-risk scores. They had no access to
other medical records and no medical examination was
included, since the aim was not to diagnose new ill-
nesses, but to register what the patient already knew. As
the study aims to reflect the everyday dental practice
with regard to elective treatment in the countries in-
volved, we thought it unwise to select a group of
respondents on the basis of (hospital) records being
available biasing the external reliability of the study.
The participants of the study modified the score in
1979 and often described an adapted ASA classification
system for use in dentistry with treatments under local
anesthesia.18,19
On self-registration it is important that the patient is
willing to cooperate, that language competence is ade-
quate, and that the dentist verifies the completeness of the
answers.20,21 There were difficulties in Greece and in
France; the sensitivity scores were poor at 87 and 85. In
Greece this was due to literacy. The solution was to have
family members help with filling in the questionnaire. In
France there exists a lack of familiarity with question-
naires. The process therefore was more time-consuming
then in other countries. After verification, the subject
coverage was 100%.
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Volume 105, Number 5 Abraham-Inpijn et al. 601

Table V. Results per participating countries

False False Questions
Country negative positive Sensitivity Specificity Prevalence (n)
Belgium 7 7 96 99 0.10 1722
France 16 10 85 99 0.09 1802
Germany 24 27 93 98 0.12 2121
Greece 35 17 87 99 0.14 2100
Hungary 9 0 96 100 0.08 2100
Iceland 4 11 98 99 0.08 2100
North. Ireland 18 23 91 98 0.11 2014
Spain 3 1 97 100 0.19 2100
Sweden 15 3 96 100 0.12 1900
The Netherlands 4 19 93 98 0.07 2100

Table VI. Cohen’s kappa for the participating countries and disease entities
Cohen’s kappa/ Cohen’s kappa/ Cohen’s Kappa/
Country country Disease disease Disease disease
Belgium 0.91 Chest pain 0.93 Allergy 0.85
France 0.81 Heart attack 0.93 Diabetes 0.95
Germany 0.89 Heart murmer 0.92 Thyroid disease 0.95
Greece 0.89 Palpitations 0.91 Liver disease 0.79
Hungary 0.97 Hypertension 0.86 Malignancy 0.90
Iceland 0.91 Bleeding 0.81 Hypervent. not known
tendency
Ireland 0.88 Epilepsy 0.97 Fainting not known
Spain 0.98 Asthma 0.94 Antibiotic not known
prophylaxis
Sweden 0.95 Lung disease 0.90 Medication 0.93
The Netherlands 0.88 Heart failure 0.87 Kidney disease 0.90

Table VII. The distribution of the ASA risk score in % the mean age of patients was 50.9, as compared with
in the participating countries 42.9 in 1998. That increase is reflected in more medi-
Country ASA I ASA II ASA III ASA IV Mean age cally compromised patients with a higher ASA risk
Belgium 35 40 14 11 51.4 score.13 The decrease in the mean percentage of ASA
France 29 53 10 08 45.3 risk score I from 57 to 28 was spectacular. A compen-
Germany 38 48 09 05 43.3 satory increase in the ASA II percentage score was
Greece 22 52 18 08 57.7
Iceland 52 39 07 02 49.1
recorded, from 26 to 47, while the ASA III percentage
N.Ireland 23 48 17 12 57.0 score increased from 11 to 16 and the ASA IV score
Hungary 28 43 12 17 46.0 from 7 to 9.
Spain 04 65 22 09 51.9 Other studies in the Netherlands and Belgium
Sweden 30 41 26 03 66.5
Netherlands 46 35 14 05 41.0
show the same reduction in the proportion of healthy
Total 28 47 16 09 50.9 patients (ASA score I from 78% to 57%) when the
mean age difference is 10 years. In one study carried
out in the Netherlands, which included 29,424 pa-
tients (mean age 37.1), the ASA risk scores were
The sensitivity score in the Netherlands (93) was ASA score II 12.7%; ASA III 5.7%, and ASA IV
lower than expected, due to language incompetence: 3.6%. In a Belgian study (mean age 47) those scores
some 41% of the residents of Amsterdam were born were 25%, 11%, and 7%.1,22 In a Spanish study with
outside the Netherlands. the EMRRH, a significant difference was found
Because of the low prevalence of diseases in the (Mann-Whitney test P ⬍ .0005) between the average
dental population studied in 1998, it was decided to age of the medically compromised patients (49.39
include dental practices in this study that were thought years; SD 19.61) and the group of patients without
to have a higher mean age. Thus, in the present study, risk-related histories (31.20 years; SD 18.97).23

602 Abraham-Inpijn et al.
The results of the EMRRH trial are good and com-
pare favorably with the specificity (98.9%) and the
sensitivity (84.8%) found in Fenton and McCartan’s
validation study of a self-administered patient health
questionnaire in a dental practice.24 Other research,
such as the PARS study (prognosis and assessment of
risk scale) have been subjected to neither validation nor
reliability tests.25
Any medical risk that is missed could be of impor-
tance for the dental treatment. During a 3-day work-
shop, all the false-positive and false-negative answers
were analyzed. False-negative replies for allergy were
due mainly to the patient’s failure to recognize the
significance of allergy to pollen. In the same way,
patients on anticoagulant therapy sometimes failed to
mention bleeding tendencies. Similar omissions were
detected with respect to the use of medication. The list
of medication taken by the patient proved to be an
important check.
The false-positive answers could easily be detected
by a brief verification of the positive answers only.
False-positive replies to allergy were due mainly to the
side effects of medication. False positive answers for
hypertension often had to do with the fact that at some
time in the past the patient had been told that his or her
blood pressure was elevated. During the follow-up val-
idation visit, the blood pressure level was found to be
within normal limits. During the workshop, questions
with false answers were reworded to reduce the inci-
dence of false replies (Appendix).
The lowest medication rate was recorded in the Neth-
erlands, due to the restrictive management of prescrip-
tion drugs. This is in contrast to the situation in Hun-
gary and Spain, where medication is often sold over the
counter.
The Cohen’s kappa of the individual countries
showed close agreement. Per item it ranged from 0.79
for liver disease to 0.97 for epilepsy (Table VI). Alco-
holic liver cirrhosis was often the bottleneck, because
people were either not aware of the seriousness of their
liver condition or denied their problem. When the dis-
crepancies were analyzed, they appeared to be the
result of noncompliances, oblivions, and inaccuracies,
and were rarely due to misunderstandings.
The increase in the number of medically compro-
mised patients, coupled with the fact that medical
emergencies do occur in dental general practice,
indicates the need for a preventive instrument. This
need is reinforced in that some dentists may not have
sufficient knowledge of medical conditions nor train-
ing in the management of calamities.26,27 This brings
us to the question: “Does the validated EMRRH have
a preventive effect?”7 The answer appears to be
“yes,” as no medical calamity was experienced by
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May 2008
any of the participating patients who used the ques-
tionnaire during a 1-year study involving dental
practices in the Netherlands. This compared favor-
ably with a control population of dentists working
with other questionnaires used to record medical
calamities.
CONCLUSIONS
The EMRRH has proved to be a useful tool in the
detection of medically compromised patients in 10
European countries. Its value lies in overcoming the
disparity between the various methods of medical
history taking in use throughout Europe, including
the problems associated with the mobility of dental
manpower within Europe. It can be helpful to pro-
vide clinical data necessary to plan health and dental
care. In this respect, a digitalized format of the
EMRRH, including the modified ASA risk score and
preventive measures per item, has been developed in
the Netherlands.
This study, which extended over many years, would
have been impossible without the support of a
number of researchers in the fields of Dentistry and
Medicine. We thank, in alphabetical order, Prof. Dr.
J. Banoczy, Prof. Dr. A. Holm, Dr. S. H. Olafsson,
Dr. Ir. J. Oosting, Prof. Dr. med. H. Spranger, and
Prof. Dr. F. Vinckier.
We are grateful for the help and encouragement
provided by Dr. J.L.M. van den Heuvel (chief dental
officer of the ministry of Health, Welfare and Sport in
The Netherlands).
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Dent J 2000;188:320-4.
27. Miyatake Y, Kazama M, Isoda M, Nejima J. Internal medicine
education in dentistry: knowledge required varies according to
dental specialty. Eur J Dent Educ 2004;8:18-23.
Reprint requests:
Luzi Abraham-Inpijn, MD, PhD
Academic Medical Centre of the University of Amsterdam
Department Internal Medicine
F4. Post-box 22660
1100 DD Amsterdam, The Netherlands
L.Abraham.Inpijn@inter.nl.net
.

EUROPEAN MEDICAL RISK RELATED HISTORY HEALTH QUESTIONNAIRE

General questions:
Name:
Address: 1. Have you ever experienced medical problems or
Postcode and city: complications during surgery or dental treatment? If so,
Date of birth: Nature of the complications?................................
Occupation: Which dentist?...................................................
Name of medical GP:
Name of specialist: 2. Have you ever had medical problems related to the
use of medication? If so,
Date: Nature of the problems?......................................
Which medication?.............................................
Medical risk based on patient’s history: ASA score Interaction with dental treatment and preventive measures:

1.......................................................................... .............. ....................................................................................................................................

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2..........................................................................
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3..........................................................................
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4..........................................................................
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Updating of patient’s history (oral): date: date: date: date: date: date: date: date: date: date:
1. Have you seen your medical GP or specialist
in the last year? yes/no yes/no yes/no yes/no yes/no yes/no yes/no yes/no yes/no yes/no yes/no
Nature of the complaints:..............................
.................................................................

2. Have there been any changes in your state of

health recently? yes/no yes/no yes/no yes/no yes/no yes/no yes/no yes/no yes/no yes/no yes/no

3. Has there been any change in your medication

recently? yes/no yes/no yes/no yes/no yes/no yes/no yes/no yes/no yes/no yes/no yes/no

CONSENSUS EMRRH Workshop Amsterdam June 2000 enabled by the Aja Ramakers-Koning Foundation (A.R.K.)
 ASA yes/no
1 Do you experience chest pain upon exertion 9. Do you suffer from asthma? If so, II 17. Do you suffer from hyperventilation? II
(angina pectoris)? If so, II Do you use any medication and/or inhalers? III
Are your activities restricted? III Is your breathing difficult today? IV 18. Have you ever fainted during dental or medical
Have the complaints increased recently? IV treatment? II
Do you have chest pain at rest? IV
10. Do you have other lung problems or a
2. Have you ever had a heart attack? If so, II persistent cough? If so, II 19. Are you on medication for any reason at
Are your activities restricted? III Are you short of breath after climbing 20 steps? III present, prescribed or otherwise? II
Have you had a heart attack in the last 6 months? IV Are you short of breath getting dressed? IV - for a heart complaint?
- anticoagulants?
3. Do you have a heart murmur, or heart valve - for high blood pressure?
disease, or an artificial heart valve? II 11. Have you ever had an allergic reaction to - aspirin or other painkillers?
Have you had heart or vascular surgery within penicillin, aspirin, latex, dental materials or - for an allergy?
the last six months? II anything else? If so, II - for diabetes?
Do you have a pacemaker? II - Prednisone, corticosteroids (systemic or topical)?
Have you ever had rheumatic heart disease? III Did this require medical or hospital treatment?III - drugs against transplant rejection?
Are your activities restricted? III Was it during a dental visit? IV - drugs against skin, bowel or rheumatic diseases?
What are you allergic to? ........................... - for cancer or blood disease?
4. Do you have heart palpitations without ..................................................................... - penicillin, antibiotics or antimicrobials?
exertion? If so, II - for sleeping disorder, depressive condition or anxiety
Do you have to rest, sit down or lie down during state?
palpitations? III 12. Do you have diabetes? II - have you ever used recreational drugs?
Are you short of breath, or pale or dizzy at these Are you on insulin? If so, II - other medication (prescribed or otherwise)?
times? IV Is your diabetes poorly controlled at present? III .............................................................
.............................................................
5. Do you suffer from heart failure? If so, II
Are you short of breath lying flat? III 13. Do you suffer from thyroid disease? If so, II ............................................................
Do you need two or more than 2 pillows at night Is your thyroid gland underactive? III ............................................................
due to shortness of breath? IV Is your thyroid gland overactive? IV

6. Have you now or in the past had high 20. Do you have to take antibiotics before dental
blood pressure? II 14. Have you now or in the past had liver treatment? II
Write down your last know blood pressure -----/---- disease? II

21. Women only, please, are you pregnant? II

15. Do you have kidney disease? If so, II
7. Do you have a tendency to bleed? If so, II Are you undergoing dialysis? III
Do you bleed for more than one hour following Have you had a kidney transplant? III
injury or surgery?
III
16. Have you ever had or do you have cancer or
Do you suffer from spontaneous bruising? IV leukemia? II
What is the disease?..........................................
Are you receiving drug therapy or have you had III
8. Do you have epilepsy? If so, II a bone marrow transplant for this?
Is your condition getting worse? III
Do you continue to have attacks despite Which medication……………………….
medication? IV Have you ever had X-ray treatment for
a tumor or growth in the head or neck? IV
ASA yes/no ASA yes/no