Intakeform (English)

Intake Form
Entry Date

daymonthyear
Initials*
First Name*
Last Name*
Company Name
Citizen Service Number*
citizen service number
Date of Birth*

daymonthyear
FemaleMale
Street and House Number*
Postal Code*
City*
Phone*
Email*
Name of General Practitioner and Practice Location
general practitioner and practice location
Weight*
Height*
BMI
calculated
We look beyond just BMI and assess your overall health profile. You are eligible if one or more of the following situations apply to you:
- BMI of 30 or higher
- BMI of 25 or higher in combination with a weight-related condition, such as high blood pressure, prediabetes, fatty liver disease, sleep apnea, high cholesterol, PCOS, joint pain, or lipoedema
- Increased waist circumference of ≥ 102 cm (men) and ≥ 88 cm (women)
- Previous lifestyle interventions had insufficient or temporary effect
Waist circumference (cm), waist circumference*
yesformerlynever smoked
Quit smoking since
Alcohol consumption*
yesnounclear
yesnounclear
meets guidelineless than guidelineunclear
Dietary pattern*

Tell us something about your healthy and/or unhealthy eating habits.0/200
GLIdietitianpersonal trainernoOther
temporary effectno effectdifficult to maintainnot applicable
semaglutide (Ozempic/Wegovy)tirzepatide (Mounjaro)
Which injection suits me?
See our website for explanation
semaglutide (Ozempic/Wegovy)tirzepatide (Mounjaro/Zepbound)liraglutide (Saxenda)Mysimbanone of the above
AmsterdamEdeHilversumLeiderdorpWormerveerZwolle
sleep apneaosteoarthritisrheumatoid arthritisgouthypertensionhypercholesterolemiaheart attack experiencedcoronary artery diseasestroke (CVA, TIA) experiencedatrial fibrillationtype 1 diabetes mellitustype 2 diabetes mellituspre-diabetesPCOSgallstonespancreatitis experiencedhepatitis experiencedfatty liverthyroid disordernone of the above
I use the contraceptive pillI have an IUD (coil)Other
YesNo
(Explanation of abdominal surgeries)
yesno
If yes, which medications do you use?
Explanation of any other medical history:
yesno
yesno
yesno
With my signature I give permission to store this data in a secure medical system*

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