download de aanvraagformulieren - Zeecentrum De Branding De ...
download de aanvraagformulieren - Zeecentrum De Branding De ...
download de aanvraagformulieren - Zeecentrum De Branding De ...
You also want an ePaper? Increase the reach of your titles
YUMPU automatically turns print PDFs into web optimized ePapers that Google loves.
Dieet:<br />
………………………………………………………………………………………..……………………………<br />
…………………………………………………………..……………………………………<br />
Verpleegkundige zorgen en frequentie:<br />
………………………………………………………………………………………..……………………………<br />
…………………………………………………………..…………………………………………………………<br />
……………………………..………………………………………………………<br />
Kinesitherapie:<br />
………………………………………………………………………………………..……………………………<br />
…………………………………………………………..……………………………………<br />
Logopedie:<br />
………………………………………………………………………………………..……………………………<br />
………………………………………………………………………………………………..<br />
An<strong>de</strong>re:<br />
………………………………………………………………………………………..……………………………<br />
…………………………………………………………..……………………………………<br />
3. Medische antece<strong>de</strong>nten<br />
Ziekten:<br />
………………………………………………………………………………………..……………………………<br />
…………………………………………………………..…………………………………………………………<br />
……………………………..………………………………………………………………………………………..<br />
…………………………………………………………………………<br />
Operaties:<br />
………………………………………………………………………………………..……………………………<br />
…………………………………………………………..…………………………………………………………<br />
……………………………..………………………………………………………<br />
4. Verklaring<br />
On<strong>de</strong>rgeteken<strong>de</strong>, bevestigt hierbij dat betrokken patiënt vrij is van besmettelijke ziekten en recent een<br />
RX-thorax heeft on<strong>de</strong>rgaan zon<strong>de</strong>r opmerkingen.<br />
Datum: ……………………..<br />
Stempel:<br />
Handtekening:<br />
8
Change language