Inschrijfformulier

Intake form
Date

daymonthyear
Initials*
First name*
Surname*
ID number or BSN*
Date of birth*

daymonthyear
Gender*

FemaleMale
Address*
Zip code*
Place of residence*
Country*
Phone number*
E-mail*
Do you smoke?*

YesFormerlyNever smoked
Quit smoking since
Eating habits*

Vertel iets over uw gezonde en/of ongezonde eetgewoonten.0/200
Physical activity according to guidelines 2017

Complies with guidelineLess than guidelineUnclear
Alcohol use*
You are eligible for treatment if your BMI is 30 or higher.

If your BMI is lower but higher than 27, please contact us via Whatsapp or email.
Weight*
Body length*
BMI
is being calculated
I want treatment with:*

semaglutide (Ozempic/Wegovy)tirzepatide (Mounjaro/Zepbound)
I recently used one of the following remedies:*

None of the abovesemaglutide (Ozempic/Wegovy)tirzepatide (Mounjaro/Zepbound)liraglutide (Saxenda)MysimbaOther
Diabetes type 2 in father, mother, brother or sister*

YesNoUnclear
Cardiovascular disease in father, mother, brother or sister before the age of 65*

YesNoUnclear
Do you have sleep apnea?*

YesNo
Do you have rheumatoid arthritis?*

YesNo
Are you being treated for hypertension?*

YesNo
Are you being treated for hypercholesterolemia?*

YesNo
Have you had a heart attack in the past?*

YesNo
Do you have coronary artery stenosis?*

YesNo
Have you had a stroke in the past (CVA or TIA)?*

YesNo
Are you being treated for atrial fibrillation?*

YesNo
Do you have diabetes mellitus?*

YesNo
Do you have gallstones, or have you had them in the past?*

YesNo
Have you had any abdominal surgery?*

YesNo
(explanation of abdominal operations)
Have you had pancreatitis?*

YesNo
Have you had liver inflammation (hepatitis)?*

YesNo
Do you have thyroid disease?*

YesNo
Are you taking any medications?*

YesNo
If yes, what medications are you taking?
Explanation of any other medical history:
I give permission to the doctors at Healthy Weight Clinics to share my medical information with my GP:*

YesNo
I give permission to the doctors at Healthy Weight Clinics to request my medication data via the 'Landelijk Schakel Punt:'*

YesNo
With my signature I give permission to store this data in a secure medical system*

Clear
Sign your signature (after processing in the medical system this form will be destroyed).
Should be Empty: