Register Your details Initial(s)* First name* Middle name Last name* Maiden name Your gender*MaleFemale Date of birth* Place of birth* Social Security Number (BSN:can be found on your ID) Street House number* Suffix Postal code* City* Landline phone Mobile* Email* Your situation Living situation*I live aloneI live with others Marital status*SingleMarriedDivorcedWidow/Widower Do you have children?*No, I do not have childrenYes, I have children living at homeYes, I have children living elsewhere If yes, how many children do you have? Work/Study Do you work or study?*I studyI workI am retiredI do not workI am on sick leave My profession is/was Authorization to cancel previous GP GP Name* GP Practice City* I authorize the request for my medical records*YesNo Please sign below to confirm that we may request your records from your previous GP. Medical History I have / I have previously had:*DiabetesLung diseaseHigh blood pressureHeart conditionsThyroid diseasesKidney diseasesStroke, TIA or CVACancerOther illnessN/A I have another illness, namely: Allergies Do you have any allergies? If so, what? Do you smoke?*YesNo Do you give permission to share medical data with other healthcare providers?* Read more: www.volgjezorg.nl/toestemmingYesNo