Register: General Practice Jutphaas.

Personal information.
  • Name: ______Gender: M / V
  • Date of birth: ______
  • Street: ______Number: ______
  • Zip code and city: ______
  • Phone number: Home ______Mobile: ______
  • E-mail:______
  • National ID number (BSN): ______

Pharmacist: ______

Insurance Company.

Health insurance company: ______
Insurance number: ______
We would like to take acopy of your insurance company.
We will destroy the copy after registration.

Extra information.

If you have previously registered with a General Practitioner in the Netherlands, then please ensure you deregister from that practice.
Contact details of the next of kin in case ofanemergency:
Name ______Phone number: ______
Do yougive consent toyourmedical information being shared withother health professionals?

We willonly share yourmedical information if we have yourpermission. Only health professionals may view yourmedical details, ifthis is deemednecessaryforyour treatment. This service has been developedfor health professionals toobtainimmediate access tomedical information toenablethemtogive the best possible care.

O I Agree, mymedical information is shared withother health providers.
O I do notagreemymedical information is share with health providers.

MedicalHistory.

To make yourregistration complete, we wouldliketoobtainsomemedical information fromyou.
Have you or anyone in your family line ever sufferedfrom:
O – Diabetes. O – Depression or Anxiety O – ThyriodDiseases
O – Lungdisease O – Eating Disorders O – Skin disorders
O – High Blood pressure O – Joint pain O – Kidneydiseases
O – Heartproblems O – Immune disorders
O – Anyotherdisease: ______
Other important medicalinformation?
O – No
O – Yes: ______Year: ______
______Year: ______
______Year: ______
Are youcurrentlyunder treatment of a specialist?
O – No
O – Yes Specialism : ______Disease: ______
Are youcurrentlytakinganymedication?
O – No
O – Yes I use: ______
______

Have you ever had anallergicreaction?
O – No
O – Yes

  • Medication: ______
  • Anesthesia / plasters / iodine: ______
  • Food: ______
  • Other: ______

Do you have a donor card?
O – No
O – Yes I donate: ______
Do you have a religion?
O – No
O – Yes: ______
Is thereanything in yourreligion we needto take into account withregardstoanymedical treatment?
O – No
O – Yes namely: ______
Have any ofyourparents, brothers or sisters ever sufferedfromany of the diseases below?
O – Diabetic Mother / Father / Brother / Sister
O – High Blood pressure. Mother / Father / Brother / Sister
O – High Cholesterol Mother / Father / Brother / Sister
O – Heartandvasculardiseaseunder65 Age: ______
O – Stroke or Cerebralhaemorrhageunder65 Age: ______
O – Lungdisease Mother / Father / Brother / Sister
O – Kidneydisease Mother / Father / Brother / Sister
O – Mentalillness______Mother / Father / Brother / Sister
O – Cancer; Type______Mother / Father / Brother / Sister
O – OtherDisease: ______Mother / Father / Brother / Sister
Do yousmoke?
O – No, I have never smoked.
O – No but I smoked _____ cigarettes a dayfor ______years
O – Yes: ______cigarettes a dayfor ______years.
Do youregularlyuse alcohol?
O – No
O – Yes; units a day ______
Have you ever been a victim of violence?
O – No
O – Yes; sexually / mental / physical
Are youdependent on anything?
O – medicines.
O – Drugs
O – Somethingelse: ______