Inschrijfformulier Engels

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Persoonsgegevens

Last 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

Adresgegevens

Adress(Vereist)

House number(Vereist)

Zip code(Vereist)

Town/city(Vereist)

Telephone number(Vereist)

Mobile phone

E-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 woonadres

Name

Adress

Town/city

Telephone number

E-mail

Gegevens vorige apotheek/apotheek op uw andere woonadres

Name

Address

Telephone number

Town/city

E-mail

Medische gegevens

Are 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 medicine

Side effects

Do you use medicines?(Vereist)

Yes

Name medicine

How many mg

Use per day

Gebruikt 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?

Do you use a weekly dosing system?

Yes

Heeft u een chronische ziekte of komt deze ziekte in uw familie voor?

diabetes mellitus

By yourself

Yes

In your family

Yes

Heart / vascular disease

By yourself

Yes

In your family?

Yes

Kidney disease

By yourself

Yes

In your family

Yes

High bloodpressure

By yourself

Yes

In your family

Yes

Asthma or COPD

By yourself

Yes

In your family

Yes

Epilepsy

By yourself

Yes

In your family

Yes

Other diseases

By yourself

In your family

Are there inherited diseases / conditions in your family?

Yes

Which?

Are you receiving a flu vaccination?

Yes

Why?

Are you being treated by a specialist?

Yes

With whom / which hospital

Have you ever had an operation?

Yes

To what and when?

Have you ever had an accident?

Yes

When?

Are there topics that you find the GP schould be informed?

Leefstijl

Do you smoke?

Yes

Previously

How many cigars / cigarettes per day?

Do you use alcohol?

Yes

How many drinks per day / per week?

Do you use drugs?

Yes

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

Exchange data with the hospital (especially the Dijklander Ziekenhuis in Hoorn) as part of a treatment

Yes

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 remarks

Confirmation 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.

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