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 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