Form for interview with GP’s Sluimer / Habets Form for interview with GP's Sluimer / Habets Your surname(Vereist) Your initials(Vereist) Your gender(Vereist)MaleFemaleDate of birth(Vereist) MM slash DD slash JJJJ E-mailadress(Vereist) Mobile phone(Vereist)Address(Vereist) Zip code and place of residence(Vereist) Citizin service number ("BSN")(Vereist)Please enter a number from 0 to 999999999.ID(Vereist)ID-cardDrivers licensePassportID number(Vereist) Health insurance company(Vereist) Health policy number(Vereist)Please enter a number from 0 to 999999999999.Date of planned interview MM slash DD slash JJJJ What is the background of your move to Deventer?(Vereist) Your last residence and GP(Vereist) Your pharmacy in Deventer(Vereist) Your medical historyHave you ever been operated upon? What kind of surgery and when?(Vereist)At present, do you consult a medical specialist on a regular basis? Which specialist and for which disease?(Vereist)Have you consulted medical specialists in the past? Which specialist, for which disease and in what year?(Vereist)Do or did you suffer from major diseases/medical conditions, that were not mentioned above?(Vereist)Have you ever experienced, or are you experiencing at present, mental health problems? Which and what was the treatment?(Vereist)Are you using drugs, wich and which dose?(Vereist)Do you use alcohol?(Vereist)YesNoHow many units a week?(Vereist)Please enter a number from 0 to 100.Do you smoke or vape?(Vereist)YesNoHow many per day?(Vereist)Please enter a number from 0 to 50.Do you use recreational drugs?(Vereist)YesNoWhich drugs?(Vereist) Are you allergic? To what?(Vereist) Is there any medication you do not tolerate?(Vereist)Diseases among your next of kinDiabetes? Who? Cardiovascular diseases? Who, which?Cancer? Who and which form?Inheritable diseases? Who, which?Your social situationAre you in a relationship, do you have kids?Are you pregnant or trying to get pregnant?(Vereist)YesNoNot applicableWhich formal education did you attend? Which job do you hold now? What kind of leisure activities do you enjoy?Do you have a religious background? Which? In case of your unfortunate demise, would you like your organs or tissues to be donated?(Vereist)YesNoOtherwise(see also: https://donorregister.nl)Would you, if ever necessary, like to receive donor-organs or tissues?(Vereist)YesNoOtherwiseWould you agree in making a summary of your medical file digital available to general practitioners and your medication-list to farmacies in Deventer (strongly recommended)?(Vereist)YesNoWe strongly recommend this to make medical services as good and safe as possible, for instance at the Huisartsenpost (evening/night/weekend medical service) and local hospital. For more info: https://www.volgjezorg.nl/het-lspDo you have certain expectations from a General Practitioner? Did you have certain good or bad experiences in the past?Now please call our frontdesk to make an appointment voor the interview with doctors Sluimer or Habets: 0570 - 643 556. Registration will only take place AFTER this interview.RecaptchaCommentsDit veld is bedoeld voor validatiedoeleinden en moet niet worden gewijzigd.
