IHCH Intake Form

Welcome to the International Health Centre The Hague (IHCH)

This intake form is meant to help the doctor devote more time to the direct conversation with you and
for us to gather important medical information about you that will help us to look after your health and
wellbeing during your stay in The Netherlands.

Personal data:
Name in full:………………………… ……………………Date of birth…………………………………

Your email address:………………………………………………

Other doctors providing medical treatment:

………………………………………………………………………………………………………..

* If you have previous medical files, please bring them upon your first visit to our Centre

Emergency contact details:

Person(s) to be informed in case of emergency:

1. Name: ………………………… Relationship: .................................

Telephone number: ......................................

2. Name: .................................... Relationship: .................................

Telephone number: ......................................

Telephone number of the person we should contact:………………….....

Data protection
All IHCH personnel, including Pharmacy, PoliClinic and Dental Care personnel need to be able to
access your medical records. All IHCH personnel is bound to medical confidentiality.

Your medical professional also needs to share important information about your health with other
healthcare providers.

Date: ................................... Signature: ……………………………………………………….

House calls
For IHCH patients living more than 10 km away from the International Health Centre The Hague, we
will not be able to provide home visits at any time. We kindly ask for your understanding. Please sign
below that you have read and understood this stipulation.

Date: ................................... Signature: ……………………………………………………….

Exchanging of Medical Data

Your medical professional needs to share important information about your health with other
healthcare providers. However, we can only do so with your explicit permission.
Therefore you hereby authorise the IHCH, including the IHCH Pharmacy to exchange your medical
data with the (Landelijk Schakelpunt-LSP) National Exchange Point.

Date: ................................... Signature: ……………………………………………………….

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Medical history

Disease/disorder Yourself In your family If yes:

YES NO YES NO Whom age

High blood pressure
Diabetes mellitus
High cholesterol
Heart disease
Vascular disease (thrombosis, intermittent
claudication)
Haemoglobinopathy (sickle-cell disease,
thalassemia)
Lung disease
Cancer
Rheumatic disease
Auto-immune disease
Disease/disorder of muscles or joints
Stomach and Oesophagus diseases/disorders
Intestinal disorders
Diseases of liver or gallbladder
Kidney diseases
Skin disease/condition
Diseases/disorders of the nervous system (incl.
epilepsy)
Mental health disorders

Any specifications about your condition:

Other conditions not mentioned above:

Other doctors providing medical treatment:

………………………………………………………………………………………………………..

* If you have previous medical files, please bring them upon your first visit to our Centre

Prevention
Do you receive an annual flu vaccination?
If not, would you like to be offered one via our practice?

Would you like to be invited for

- a cardiovascular risk assessment (family history, lifestyle, blood pressure, lab work)
- a well-woman consultation (PAP smear, ultrasound, breast examination)
- a general health check?

For women
Do you have any children? (If yes, how many?)

Have you ever had any significant gynaecological/obstetrical problems, either recently or in the past?

Date of last gynaecological check-up (incl. PAP test):

Have you ever had a mammogram? If yes, when was the last one?

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Previous hospital admissions and/or treatments by specialists

Date Operations/Admissions Where/Location

If you have ticked any of the above, please describe the problem and treatment you have
experienced:

Please list any prescription medicines you regularly take

How many tablets do you take and when

Name Dosage (in When needed Morning Noon Evening
ml or mg) (how often)

Please list any over-the-counter medicines (incl. supplements) you regularly take

How many tablets do you take and when

Name Dosage (in When needed Morning Noon Evening
ml or mg) (how often)

Lifestyle

What is your weight (in kilograms)?..................... What is your height (in centimetres)?..............

Do you do any form of physical activity? Yes/No

If so, what (bicycle, gym, etc.)? How often during the week?

Do you drink alcohol? Yes/No?

If so, what? Daily / weekly amount?

Do you smoke? Yes/No?

If yes, since when? How many cigarettes per day?

How would you rate your health during the past year, on a scale from 0 to 10;........(0= very bad, 10=
excellent)?

Would you like us to arrange a consultation in order to find out how to improve this?

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Social circumstances

Marital status: Single / widowed / divorced / separated / married / living with a partner

Occupation/job ……………………………… or are you a Stay-at-home-parent;

Employed (Name of employer..........................); Self-employed; Other .............................

Children: (ages) …………………………………………

School Kindergarten

We would like to know more about you and your thoughts about the IHCH (optional)

IHCH offers these additional services which you may also be interested in:
 Specialist services: Cardiology; Dermatology; Ear-nose-throat; Gynaecology, Internal
medicine; Neurology; Ophthalmology; Paediatrics, Surgery and Urology – Please check our
website for the latest updates
 IHCH Dental Clinic
 Travel Clinic including, Yellow Fever Certificate
 Allergy Testing; Sleep Diagnostics; Spirometry; Diabetes Program; Well-Baby and Well-Child
Programs; Integrative Woman’s Health; Orthomolecular/Nutritional Medicine
 Prevention consultations (General, Gynaecology, Cardiology)

Which services would you like us to offer in the future (please circle):
 Smoking cessation
 Other?:......................................................................................

We are happy to inform you about the numerous services we already have on offer in more detail
(please check our website www.ihch.nl).

Do you have any further questions or suggestions?

Thank you for your time

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