Vragenlijst nieuwe patient

Personal data
Gender
Male
Female
Marital status
Married
Unmarried
Address data
Insurance details and social security number
Derma Rijnmond has or does not have a contract with my health insurance company.
Yes
No
Details GP
Details Pharmacy
QUESTIONS REGARDING risk of infection MRSA *) or BRMO **)
1. Are you known as a carrier of a resistant bacteria, such as MRSA or BRMO ?
2. Coming from a division of a Dutch care institution where an outbreak dominated by a
resistant microorganism (MRSA or BRMO) ?
3. Are you covered in the last two months in a foreign hospital or healthcare facility
behandeld of opgenomen geweest?
4. Do you have professional contact or do you live on a farm with pigs, veal
or poultry meat ? (This is not meant: hobby farmers and petting zoos )
5. Are you a family member and / or caregiver of an MRSA positive patient?
6. Are the answers to the above questions still correct at the time of treatment?
Lifestyle
Do you smoke?
Yes
No
Do you drink alcohol?
Yes
No
Do you use drugs?
Yes
No
Medical data
Are you hypersensitive to, or familiar with side effects for medicines or excipients?
Yes
No
Do you use self-care products / alternative products / nutritional supplements?
Yes
No
Do you have problems using a medicine?
Yes
No
Are there inherited diseases / conditions in your family?
Yes
No
Are you receiving a flu vaccination?
Yes
No
Are you being treated by a specialist?
Yes
No
Have you ever had surgery?
Yes
No
Do you have a chronic illness or does this illness occur in your family?
Diabetes
U
Family
Both
n.v.t.
Heart / vascular disease
U
Family
Both
n.v.t.
Kidney disease
U
Family
Both
n.v.t.
High bloodpressure
U
Family
Both
n.v.t.
Asthma or COPD
U
Family
Both
n.v.t.
Epilepsy
U
Family
Both
n.v.t.
I confirm that the above information is true and accurate:
Versturen

Glashaven 14-G, 3011 XH Rotterdam | T 010 23 321 53 | E info@derma-rijnmond.nl
Woordbouwerplein 1, 3224 XL Hellevoetsluis
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