Registration form Registration Form You can only fill out this form if you have had contact with the assistant Stap 1 van 3 33% Personal informationInitials(Vereist) Dhr.Mw.MissMs.Dr. Initials First Name(Vereist) First name Surname(Vereist) Surname Sex(Vereist) Female Male Date of Birth(Vereist) DD dash MM dash JJJJ Street and housenumber(Vereist) Zipcode(Vereist) City(Vereist) Phone number at home(Vereist)Mobile phone number(Vereist)Insurance company(Vereist) Insurance number(Vereist) E-mail(Vereist) BSN number(Vereist) Pharmacy Previous general practitioner(Vereist) Town previous general practitioner(Vereist) Medical informationDo you use medication?(Vereist) yes no MedicationNamemgUse per day Toevoegen RemoveDo you have an allergie for medicationMedicationSide effect Toevoegen RemoveDo you have Diabetes?(Vereist) Yes No Do you have heart disease?(Vereist) Yes No Do you have kidney disease?(Vereist) Yes No Do you have high bloodpressure(Vereist) Yes No Do you have asthma or COPD(Vereist) Yes No Do you have epilepsy(Vereist) Yes No Do you have any other disease?Disease Toevoegen RemoveAre there any inherited diseases / conditions in your family?If so what disease? Toevoegen RemoveDo you get a flu vaccination?If so what is the reason? Toevoegen RemoveAre you being treated by a specialistIf so which specialist? Toevoegen RemoveHave you ever had surgery?If so, to what and when? Toevoegen RemoveHave you ever had an accident?If so, what happend en do you have lasting complaints? Toevoegen RemoveDo you smoke?If you do, how much a day Toevoegen RemoveDo you use alcoholIf so, how much a day/week Toevoegen RemoveDo you use drugs?If so, which and how much? Toevoegen Remove PermissionI agree to requesting and exchanging my medical data with the previous GP(Vereist) Yes I give Dr. Willemse permisson to share my medical file at the LSP(Vereist)At the website below you can find all the information about the LSP. https://www.volgjezorg.nl/en/permission Yes, I give permisson No, I don't give permission RecaptchaEmailDit veld is bedoeld voor validatiedoeleinden en moet niet worden gewijzigd.