Royal Doctors

It takes approximately 10 minutes to complete this questionnaire.
The second opinion will be issued on the basis of this questionnaire AND your medical file.
Your answers are, of course, strictly confidential.

1. PERSONAL INFORMATION

Surname + First name: *

Street address:

Postal code + city:

Country:

Sex:

Male

Female

Date of birth:

Citizen service number/ID number:

Telephone:

Email: *

Insurance company:

Are you employed?

Nee

If yes, what job?

Can you currently perform your job?

Nee

Part-time

If you are incapacitated for work, for how long?

< 1 month

1-3 months

3-6 months

> 6 months

Your height:

Your weight:

Do you smoke?

Nee

Do you participate in any sports?

Nee

If yes, which sport?

If yes, how many hours / week?

2. SHORT QUESTIONS CONCERNING YOUR CURRENT MEDICAL SITUATION

Do you currently have a diagnosis?

I don’t know

Nee

Do you currently have a treatment plan?

I don’t know

Nee

Has your treatment already started?

Nee

If yes, since when??

How many doctors have you seen about your current medical situation?

How many hospitals have you been to about your current medical situation?

Which doctor do you regard as the coordinating doctor for your medical situation?

General practitioner

Specialist

Other

Name of doctor:

For what reason(s) are you requesting this second opinion?

I want more certainty/confirmation/peace of mind.

I want to know if there are other options.

I have no confidence in the proposed diagnosis/treatment plan.

My current treatment plan isn’t working.

The second opinion was recommended by my doctor.

I want to use the second opinion in a legal context.

Other

If other, which?

3. YOUR CURRENT MEDICAL SITUATION

What are your current symptoms?

What is your current diagnosis?

What is your current treatment plan?

What tests have already been run? + dates of these tests, if possible.

What tests are planned for the future?

Do you have any other disorders/diseases? E.g. diabetes, allergies, etc.

What medication are you currently taking? Fill this out as completely as possible.

Are there any other hereditary disorders/diseases in your family? E.g. cardiovascular diseases, etc.

4. NOW YOU CAN ASK ROYAL DOCTORS FIVE QUESTIONS.

Question 1

Question 2

Question 3

Question 4

Question 5

5. EXTRA INFORMATION / REMARKS

Write any extra information and/or remarks that may be important to us here:

Upload specific documents you want to send us

Upload file

6. GENERAL TERMS AND CONDITIONS

I accept the General Terms and Conditions

I hereby give permission to Royal Doctors to register and use my (medical) data. Royal Doctors only uses this information to be able to advise you optimally about the questions you have asked us. The health insurer/ employer does not have access to your file. Royal Doctors does not store your data longer than necessary. You can access your data on request.

I agree