Diagnostiek reserveringsaanvraag

Het invullen van onderstaande vragen helpt ons om je nog sneller en gerichter van dienst te zijn bij het inplannen van jouw afspraak. Het geeft ons inzicht in uw medische voorgeschiedenis en situatie zodat wij u voorlichting op maat te kunnen geven ter voorbereiding op uw afspraak.

Let op: Als je een vraag met ‘ja’ beantwoordt betekent dit niet automatisch dat je niet bij ons in zorg kunt komen. Wij zullen jouw situatie telefonisch bespreken om de context beter te begrijpen, onder andere in combinatie met de informatie van jouw verwijsbrief. Het is dus belangrijk dat u onderstaande vragen eerlijk beantwoordt.

Name(Required)
Are you using medication prescribed by a physician? (This does not mean paracetamol or other medication available at the drugstore).
Are you taking medication prescribed by a physician? (This does not mean paracetamol or other medication available at the drugstore).(Required)
Is there anything in your health that we need to know about, such as high blood pressure, heart problems, epilepsy and thyroid problems or other medical issues?
Is there anything in your health that we need to know about, such as high blood pressure, diabetes, epilepsy and thyroid problems? Or are there other medical issues we should know about?(Required)
Have you (in the past few years) received (been receiving) treatment from a hospital specialist?
Have you (in the past few years) received (been receiving) treatment from a hospital specialist?(Required)
Are you (in recent years) in treatment (or have you been in treatment) at a mental health facility or with a psychologist? For example, in the context of burnout or depression symptoms.
Are you (recently) in treatment at a mental health institution, with a psychologist or the like?
Are you using 1 or more of the following drugs:
- Alcohol (answer yes if you drink daily and cannot stop).
- Drugs (cannabis, cocaine, XTC, other substances)
Do you use 1 or more of the following substances: Alcohol (answer yes if you drink daily and cannot stop). Drugs (cannabis, cocaine, XTC, other substances).(Required)
Are you pregnant or breastfeeding?
Are you pregnant or breastfeeding?(Required)