Inschrijfformulier Engels Inschrijfformulier Engels Stap 1 van 8 12% PersoonsgegevensLast name(Vereist) Maiden name Initials First name(Vereist) Date of birth(Vereist) DD slash MM slash JJJJ Place of birth Male / female(Vereist) Male Female Job Marital status AdresgegevensAdress(Vereist) House number(Vereist) Zip code(Vereist) Town/city(Vereist) Telephone number(Vereist)Mobile phoneE-mail(Vereist) Verzekeringsgegevens en BSN-Nummer Name health insurancy company(Vereist) Insurance number(Vereist) Insurance start date(Vereist) MM slash DD slash JJJJ Social security number(Vereist) Gegevens vorige huisarts/huisarts op uw andere woonadresName Adress Town/city Telephone numberE-mail Gegevens vorige apotheek/apotheek op uw andere woonadresName Address Telephone numberTown/city E-mail Medische gegevensAre you allergic to or familiar with side effects for drugs or additions? (for example. Penicilline, lactose)? If so, for which medicines and/or additions and what are the side effects?Name medicineSide effects Toevoegen RemoveDo you use medicines?(Vereist) Yes No Name medicineHow many mgUse per day Toevoegen RemoveGebruikt u zelfzorgmiddelen / alternatieve middelen / voedingssupplementen? (denk hierbij aan pijnstillers, maagtabletten, vitaminepreparaten, Sint Jans kruid)Dou you have problems by using medicines?Which medicine gives problems?What problem do you have? Toevoegen RemoveDo you use a weekly dosing system? Yes No Heeft u een chronische ziekte of komt deze ziekte in uw familie voor?diabetes mellitusBy yourself Yes No In your family Yes No Heart / vascular diseaseBy yourself Yes No In your family? Yes No Kidney diseaseBy yourself Yes No In your family Yes No High bloodpressureBy yourself Yes No In your family Yes No Asthma or COPDBy yourself Yes No In your family Yes No EpilepsyBy yourself Yes No In your family Yes No Other diseasesBy yourselfIn your family Toevoegen RemoveAre there inherited diseases / conditions in your family? Yes No Which?Are you receiving a flu vaccination? Yes No Why?Are you being treated by a specialist? Yes No With whom / which hospitalHave you ever had an operation? Yes No To what and when?Have you ever had an accident? Yes No When?Are there topics that you find the GP schould be informed? LeefstijlDo you smoke? Yes No Previously How many cigars / cigarettes per day?Do you use alcohol? Yes No How many drinks per day / per week?Do you use drugs? Yes No Which? As of February 19, 2025, the practice will use Mitz to register permission to share medical data with other healthcare providers. We request that you record your wishes here on mijnmitz.nl ! See also our website page https://praktijknibbixwoud.praktijkinfo.nl/onze-praktijk-gebruikt-nu-mitz-voor-het-online-vastleggen-van-toestemmingen/Request medication data from a previous pharmacy Yes No Exchange data with the hospital (especially the Dijklander Ziekenhuis in Hoorn) as part of a treatment Yes No With this permission we can see (for example) laboratory results, x-ray results and hospital appoinments in the Dijklander hospital administraton. This is helpful for us since (for example) we do not have to repeat tests like the same laboratory investigatons (we do not standard receive a copy of results of specialist-requested tests). Other remarksConfirmation of identity and consent forms It is mandatory to bring a copy of passport / ID / driver's license to the practice. You will also receive permission forms on the practice so that we can save it filled in. Please complete these LSP and Dijklander Hospital permission forms and hand them over to an assistant.RecaptchaGeen titel Geen titel AfbeeldingToegestane bestandstypen: jpg, jpeg, png, gif.NameDit veld is bedoeld voor validatiedoeleinden en moet niet worden gewijzigd.