VERWIJSBRIEF DIËTIST
Naam cliënt _________________________________________
Adres _________________________________________
Postcode en plaats _________________________________________
Geboortedatum _________________________________________
Telefoon _________________________________________
BSN _________________________________________
Diagnose
O Overgewicht O Diabetes
O Hypercholesterolemie O Hypertensie
O COPD O Ondergewicht
O O
Vraagstelling: _________________________________________
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Laboratoriumonderzoek
O Glucose nuchter O Tensie
O Hba1c O Cholesterol totaal
O TGL O HDL
O Bloeddruk O LDL
O TSH / T3 / T4 O Overig
Medicatie _________________________________________
_________________________________________
_________________________________________
_________________________________________
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Naam arts / specialist _________________________________________
Datum ________________ Handtekening ___________
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