The practice Location Look inside Consultation hours Accessibility Vision Midwives Cover Assistants Case Manager Becoming pregnant Pregnancy Approach Centering Pregnancy Prenatal screening Calling Instructions Pregnancy Arrangements after the first check-up Pregnancy course Information sessions Miscarriage Pregnancy week by week Ailments Nutrition and pregnancy Alcohol and pregnancy Ultrasound scans Medical ultrasound scans Fun ultrasound scans The delivery Calling instructions Hospital or home birth Birthing positions Birth plan Dealing with pain What do you need? Postnatal care Postnatal care Breast or Bottle feeding Follow-up check Contraception Coil Information Know and Arrange Addresses and links Complaints Procedure Disclaimer Reviews Client survey Costs Intake questionnaire Contact Intake questionnaire Personal information Please complete the contact form below. We will contact you as soon as possible to create an appointment. If you do not receive any reply withing 2 working days most probably something went wrong. We will you then to call the assistant via phone number 040- 255 39 75. An assitant is present every working day between 8.00am- 5.30pm. * If applicable Personal details Insurance Occupation Marital status Medical background During the first check-up we would like to learn more about both your and your partner’s medical background, any previously born child(ren) and both families. In preparation we ask you answer a number of questions as good as you can. Have you ever miscarried? YesNo Have you ever had an abortion? YesNo Are any of these children from a previous relationship? YesNo Does your partner have children from a previous relationship? YesNo Are you certain of this? YesNo Do you have a regular cycle? YesNo Did you use medication to get pregnant? YesNo Did you take a pregnancy test? YesNo Do or did you use vitamins or folic acid? YesNo Do you smoke? YesNo *Does your partner smoke? YesNo Did you drink alcohol prior to getting pregnant? YesNo Do or did you use drugs and/or methadone? YesNo General Have you ever experienced a serious disease? (i.e. heart, liver, lungs, kidneys, bladder, brain, gallbladder, stomach, thyroid, spine, bowels) YesNo Have you ever seen a specialist? YesNo Have you ever had surgery? YesNo Have you ever had a blood transfusion? YesNo Are you opposed to a blood transfusion if necessary? YesNo Have you seen a gynaecologist previously? YesNo Do you suffer from varicose veins (or have in the past?) YesNo HHave you ever had thrombosis or another type of blood disease? YesNo Do you suffer from haemorrhoids? YesNo Do you ever have cystitis? YesNo Have you ever had a cold sore? YesNo *Has your partner ever had a cold sore? YesNo Did you have chicken pox (as a child)? YesNo Did you go through the national vaccination program (as a child)? YesNo Have you been in a foreign hospital recently (past 3 months)? Or are you familiar with MRSA? YesNo HHave you ever had a sexual transmitted disease? YesNo Have you ever been treated by a psychologist or psychiatrist or supported by a social worker? YesNo Did/do you use medication for this? YesNo Because the pregnancy and delivery is a very intimate happening it may invoke feelings from the past. Have you ever had an unpleasant sexual experience or experienced (domestic) violence and/or abuse? YesNo Family Is your partner healthy? YesNo Does anyone in your direct family (brother, sister parents) have diabetes? YesNo Does high blood pressure occur in your direct family? YesNo Does anyone in your direct family have an abnormal thyroid function? YesNo Are you aware of any hereditary diseases or birth defects occurring in either of your families? (think of spina bifida, hydrocephalus, muscle disease, heart defects, blood diseases, mental disabilities) YesNo
