040-2553975

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