Aditional questionaire

Welcome in our practice. In addition to your medical file from your previous general practitioner, we would like to ask you some questions. 

You can skip any questions you would prefer not to answer.




    Date of birth


    What kind of work do/did you do?


    How do you consider the state of your own health. E.g. lifestyle, physical wellbeing and mental wellbeing.

    Do you use any over the counter medication or vitamins?

    If so, which ones?

    Are you familiar with any allergies?

    If so, which ones?

    Do you smoke?

    If so, how many per day?

    Do you use alcohol

    If so, how many glasses per week?

    Do you take any drugs?

    If so, which ones?

    Did you experience any major events you consider important for your doctor to know about. (E.g. the loss of someone dear to you, traffic accidents, incapacity for work, reffugee, (sexual) violence, natural disaster).

    Room for any other remarks for your general practitioner:

    All the information given above is subject to doctor-patient confidentiality.