Corpio

Personal data

Last name

Maiden name

Initials

First name

Date of birth

Gender

Profession

Marital status

Address data

Street

House number

Zip Code

City or residence

Mobile phone

Landline phone

Email

Insurance details, citizen service number and pharmacy

Health insurance

Insurance number

Citizen service number

Preferred pharmacy

Details of previous GP

Name

Address

Residence

Phone

Email

Medical data

Are you hypersensitive or do you have side effect of certain medicines or excipients? yes no

If so, for which medicines, what are the symptoms?

Do you use medications? yes no

If so, which medications? How many mg and amount/use per day/week?

Do you use self-care products / alternative products / food supplements yes no

If so, which?

Do you use a drug dosing system? yes no

Do you have a chronic illness or do these illnesses run in your family? yes no

Diabetes

Heart/vascular disease

Kidney disease

High bloodpressure

Asthma or COPD

Epilepsy

Other disease(s)

Do you have hereditary diseases in your family? yes no

If so, which?

Are you being treated by a specialist? yes no

If so, where and at which hospital?

Have you ever had surgery? yes no

If so, what for and when?

Have you ever been in an accident? yes no

If so, what were the effects/consequences?

Are there any topics that you think the GP should be aware of?

Lifestyle

Do you smoke? yes no

If so, how much per day?

Do you use alcohol? yes no

If so, how much per day?

Do you use drugs? yes no

If so, which?

The patient's consent for requesting and exchanging data with other healthcare providers, with due observance of medical professional secrecy.

Requesting your medical records from your previous GP is necessary to provide medical care.

Requesting medical data from your previous pharmacy yes no

Exchanging data with the hospital in the context of treatment yes no

Requesting data from other health care providers Yes always Yes except: No never No except:

If you have exceptions, what are they?

LSP akkoord niet akkoord

You can call after 4 weeks to see if your file is in, so we can have an introductory meeting. For this, you must identify yourself to the assistant for the first time with an official document (passport, driving license, etc...). This is required by the ID Act.

I agree to the request and exchange of my data as indicated above.

yes

Name

Date of birth

BSN number

Date

Signature

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Formulier