Register

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Patient Information
Full name*:
Date of Birth*:
Male / Female*:		Male Female
Home Adress*:
Postal Code*:
Phone Number:
Mobile Number*:
Email Adress*:
BSN Number*:
Your Pharmacy*:		Apotheek Voorschoten, LeidsewegApotheek Meidoorn, VoorstraatApotheek Schoolstraat, SchoolstraatApotheek Hofland, PlanciusplantsoenNo Apotheek (Pharmacy) yet
Hereditary diseases
Diabetes Mellitus*:		Yourself Family No
High Cholesterol:		Yourself Family No
High bloodpressure:		Yourself Family No
Stroke:		Yourself Family No
Cardiovascular disease before 60th birthday*:		Yourself Family No
Athma/COPD/emphysema*:		Yourself Family No
Thrombosis:		Yourself Family No
Breastcancer:		Yourself Family No
Other cancers:		Yourself Family No
Allergies:		Yourself Family No
If yes, to what?:
Lifestyle
Do you smoke?*:		Yes No
What is your weight?( in kg)*:
What is your height? (in cm)*:
Medication
Do you use medication?*:		Yes No
Do you use contraception?:		Yes No
If yes, what?:
Opt-in (check www.vzvz.nl)
Opt-in (check www.vzvz.nl)*:		Yes No
Consent
Consent to register with PRAKTIJK61*:		Yes