The practice Location Look inside Consultation hours Accessibility Vision Midwives Cover Assistants Case Manager COVID-19 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 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 Info 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 within 2 working days most probably something went wrong. Please call the assistant on phone number 040- 255 39 75 and she will help you further. An assistant is present every working day between 8.00am- 5.30pm. * If applicable Personal details Marital status Insurance Occupation ParttimeFulltime ParttimeFulltime Current pregnancy 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 been guided by us before in your previous pregnancy? YesNo 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 Do you use folic acid of vitamins for pregnancy? YesNo Did you take a pregnancy test? YesNo Are you using medication or have you taken medication in the past? YesNo Do you smoke? YesNo Did you drink alcohol prior to getting pregnant? YesNo Do or did you use drugs and/or methadone? YesNo Does your partner smoke? * YesNo Medical background Have you ever seen a specialist in a hosptial? YesNo Have you ever been treated or supported by a practice nurse, social worker, psychologist or psychiatrist? YesNo Do you also use medication for this? YesNo Because pregnancy and childbirth is a very intimate event, it can one day evoke feelings from the past. Have you ever had unpleasant sexual experiences? Or had to deal with (domestic) violence and/or abuse? YesNo Have you ever been ill for a long time? YesNo Have you ever had surgery? YesNo Have you ever had a blood transfusion? YesNo Are you opposed to a blood transfusion if necessary during labour? YesNo Do you suffer from an allergy? YesNo Do you suffer from varicose veins (or have in the past?) YesNo Do you suffer from haemorrhoids? YesNo Did you have a bladder infection last year? YesNo Have you ever had a cold sore? YesNo Has your partner ever had a cold sore?* YesNo Have you ever had a sexual transmitted disease? 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)? YesNo Do you work/live at a livestock farm because of MRSA? YesNo Familiy Is your partner healthy?* YesNo Is your parents and/or brother/sister suffering from diabetes? YesNo Does your parents and/or brother/sister have high blood pressure? YesNo Do your parents and/or brother/sister have abnormal thyroid functions? YesNo Are you aware of any hereditary diseases or birth defects occurring in either of your families?YesNo
