Registration form (English) Registration form (English) Registration form to become a patient in our practice Stap 1 van 8 12% Sex(Vereist)MaleFemaleLast name(Vereist) Maiden name Initials First name(Vereist) Date of birth(Vereist) MM slash DD slash JJJJ Place of birth Profession Marital status Street name(Vereist) House number(Vereist) Zip code(Vereist) Place of residence(Vereist) Phone number(Vereist) Mobile phone number E-mail(Vereist) Name of health insurer(Vereist) Insurance number(Vereist) Date of start insurance(Vereist) MM slash DD slash JJJJ Citizen Service Number(Vereist) Name of previous general practitioner/ general practitioner at your previous home address Address Place Phone number E-mail Name of previous pharmacy/ pharmacy at your previous home address Address Place Phone number E-mail Are you hypersensitive to or familiar with side effects of medicines or additives? (for example penicillin, lactose) If so, for which medicines and/or excipients; what are the side effects?Medicine and/or excipientMedicine and/or excipientside effect Toevoegen RemoveAre you taking medications?(Vereist)YesNoPrevious question answered yes, please complete the following:drug namequantity in milligramsuse per day Toevoegen RemovePrevious question answered yes, please complete the following:Do you use self-care products / alternative products / nutritional supplements? (think of painkillers, stomach tablets, vitamin preparations, St. John's herb)Do you have problems using a medicine? For example, difficulty swallowing, opening packaging, eye drops, injecting insulin, forgetting to take it on time?Which medicine causes problems?What problem do you have? Toevoegen RemoveDo you use a weekly dosing system for your medicines?(Vereist)YesNo DiabetesYou(Vereist) Yes No In your family(Vereist) Yes No Cardiovascular diseaseYou(Vereist) Yes No In your family(Vereist) Yes No Kidney diseaseYou(Vereist) Yes No In your family(Vereist) Yes No High blood pressureYou(Vereist) Yes No In your family(Vereist) Yes No asthma or other chronic obstructive pulmonary diseaseYou(Vereist) Yes No In your family(Vereist) Yes No EpilepsyYou(Vereist) Yes No In your family(Vereist) Yes No Other diseasesYouIn your family Toevoegen RemoveDo hereditary diseases/conditions run in your family? Yes No Which one?Will you receive a flu vaccination?(Vereist) Yes No Why?Are you being treated by a specialist?(Vereist) Yes No With whom / which hospital?Have you ever had surgery?(Vereist) Yes No To what and when?Did you ever had an accident?(Vereist) Yes No When?Are there topics that you think the GP should be aware of? Then write this down here: Do you smoke?(Vereist) Yes No How many cigars/cigarettes per day?Do you use alcohol?(Vereist) Yes No how many glasses per week?Do you use drugs?(Vereist) Yes No Which one? When you give opt-in consent on your GP’s registration form, you are giving permission for your medical data to be shared via the National Exchange Point (LSP). This means that certain healthcare providers can access your medical records, but only under strict conditions and when necessary for your care. The healthcare providers who can gain access are typically: 1. Other general practitioners: for example, a substitute GP or a GP you visit outside of regular hours. 2. Pharmacists: to review your medication details and to prevent any undesirable combinations of medications from being prescribed. 3. Hospitals and medical specialists: when you are referred to a specialist or admitted to a hospital. 4. Emergency departments: in the case of an emergency, doctors in the emergency department can quickly access your medical records. Sharing your data via the LSP is optional, and you can always decide which healthcare providers can or cannot have access. You can also withdraw your consent at any time.Make data available to healthcare providers (Opt-in)(Vereist) Yes No No, because:Other commentsI agree to the request and exchange of my data as indicated above*(Vereist) Yes CAPTCHAEmailDit veld is bedoeld voor validatiedoeleinden en moet niet worden gewijzigd.