Registration form Registration form Stap 1 van 7 14% You can register with Huisartsenpraktijk Tuinwijk if you live in postcode area: 3514, 3515 Due to shortness of staff, it is possible that your registration cannot be processed immediately. You will receive a confirmation email when your registration is completed. For urgent cases please contact your current GP. Personal informationFirst name(Vereist) Surname(Vereist) Initial(s)(Vereist) Date of birth(Vereist) DD slash MM slash JJJJ BSN number(Vereist) Male/Female(Vereist) Male Female Marital status Place of birth and country(Vereist) Profession AddressMobile number(Vereist)Telephone numberEmail address(Vereist) Streetname(Vereist) Number(Vereist) Postcode(Vereist) City(Vereist) household composition(Vereist) Single Living together Family Student Work Study Pension benefit Profession/study Insurance information Name insurance(Vereist) Insurance number(Vereist) Details of previous pharmacy/pharmacy at your other home addressName of previous pharmacy Place previous pharmacy Your (new) pharmacy in Utrecht(Vereist) Details of previous GP/GP at your other home addressName previous Dutch GP(Vereist) Place previous GP(Vereist) Consent to exchange medical data LSP(Vereist)YesNoIf you need a doctor in the evening, night or weekend, it may be important that this doctor can view your medical data, for example medications that you are taking, to which you are hypersensitive and to which you have recently been to the doctor, and diseases or conditions that affect you. We may only share this data with the regional healthcare system if you give permission for this. Information about this can also be found at www.VZVZ.nl or in the information brochure available at the practice. Do you agree to registering your details for both your GP and your pharmacy?Do you give your previous general practitioner permission to send us your medical file?(Vereist) Yes No Are you hypersensitive to or familiar with side effects to medicines or excipients? (eg penicillin, lactose) If yes, for which medicines and/or excipients; what are the side effects?Do you use medication? If yes, which one?Name medicineHow many mgTimes per day Toevoegen RemoveAre you allergic to medication? If yes, which one?Medicine and/or excipientSide effect Toevoegen RemoveDo you have problems using a medicine? For example, difficulty swallowing, opening packaging, eye drops, injecting insulin, forgetting to take it on time? HiddenWhich medicine causes problems?What problem do you have? Toevoegen RemoveDo you get an annual flu vaccination? Yes No What blood group do you have? If you don't know mark ?(Vereist) Do you have a chronic illness or does this illness run in your family?Are you suffering from(Vereist) Diabetes Cancer High blood pressure / cardiovascular disease kidney disease Asthma/COPD Epilepsy rheumatism Stress/depression Thyroid disease Other serious/hereditary illness None mark whichever applies.Does a close family member suffer from(Vereist) Diabetes Cancer High blood pressure / cardiovascular disease kidney disease Asthma/COPD Epilepsy rheumatism Stress/depression Thyroid disease Other serious/hereditary illness None mark whichever applies. Are you being treated by a specialist? Yes No If so, with which specialist and hospital?Have you ever been operated on and/or admitted? Yes No For what and when?Have you ever had an accident? Yes No If so, when and what injuries did you sustain?Topics that you think the GP should be aware of LifestyleDo you smoke? or have you smoked in the past? Yes No 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 and how many times?RecaptchaGeen titelEerste keuzeTweede keuzeDerde keuzeNameDit veld is bedoeld voor validatiedoeleinden en moet niet worden gewijzigd.
