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Intake

Personal registration
General health and medication
Medical history of your partner and family

What's your name? *

Date of birth *

Address *

Zipcode *

City *

Email address *

Phone number *

Citizen’s service number (this probably doesn’t apply to expats and temporary residents) *

Insurance compagny

Insurance number *

General practitioner *

Marital status *

Country of birth *

In which country was your mother born? *

In which country was your father born? *

What does your household look like? *

Wat is de hoogste opleiding die je hebt afgemaakt? *

Do you have good reading and writing skills in (Dutch)? *

Do you practice a religion? *

Do you work? (voluntary or paid) *

How many hours a week?

What kind of work do you have?

Standing or stressful work? *

Do you come into contact with chemical substances and/or radiation? *

Do you work with small children? *

Do you have hard-to-repay debts or are you in debt restructuring *

Partner (indien van toepassing)

What is your patners name?

Occupation of partner

Is there a cousin relationship between you? *

Mobile number of partner

Email address of partner

Does your partner work? If so, what kind of work? Does your partner come into contact with chemical substances?

In which country was your partner been born?

Does your partner have any children from previous relationships??

If so, are the children healthy?

What's your height? (in CM) *

What's your weight before you got pregnant? (in KG) *

Do you visit the general practitioner regularly? *

If yes, please explain

Do you visit a specialist regularly? *

If yes, please explain

Explanation

How is your general health?

Have you ever had surgery? *

If yes, please explain

Explanation: for what and how did the anesthesia go?

For what and how did the anesthesia go?

Have you ever had a blood or blood product transfusion? *

If yes please explain

Explanation: for what?

For what, and how did the anesthesia go?

Are you familiar with clotting disorders such as thrombosis or Factor V Leiden?

Do you have medically relevant allergies? *

If yes please explain

Explanation: what kind of allergies?

For what, and how does it manifest?

Do you use medication? *

Indien het antwoord ja is, graag een toelichting invullen.

Soort medicatie *

Geen *

None
Cough syrup
Homeopathic remedies
Insuline
Medications for depression (e.g. Sertraline, Citalopram)
Antibiotics (e.g. penicillin)
Pijnkillers (vb Paracetamol)
Medications for high blood pressure
Medications for nausea and vomiting
Anti-inflammatory drugs (e.g. ibuprofen)
Antiepileptic drugs
Steroïds (vb prednison)
Thyroid medication
Sleep and tranquilizers (e.g. diazepam)
Others

What kind of medication do you use other than mentioned

How often do you take it, and what is the dose??

Have you ever had a cold sore? *

Have you ever had a urinary tract infection (UTI) *

Have you ever had a vaginal yeast infection? *

Have you ever had gum disease? *

Do you take folic acid or prenatal vitamins? *

If you are not currently taking folic acid, we advise you to start taking 0.4/0.5mg of folic acid daily

When did you start taking multivitamins or folic acid? *

Name of the medicine

Chronic illnesses *

None
Cardiovascular diseases
Lungdiseases
Kidney disease
Liver disease
Autoimmune disease
Depression
Epilepsy
Thyroid disorders
Diabetes
Other

Explanation of chronic condition / illness

Have you ever had a smear test done? (For example, for cervical cancer screening *

Explanation: when was it, and what was the result?

Have you ever been treated for a sexually transmitted infection (STI)? *

Which STI?

Were you vaccinated as a child according to the standard National Immunization Program? *

Chickenpocx (Varicella)

Have you been admitted to a foreign hospital in the past 6 months? *

Do you work professionally with pigs, calves, or broiler chickens? *

PPsychosocial factors

We ask the following questions because these topics may affect your experience of pregnancy, childbirth, or the period afterward. We appreciate being informed about this so we can take it into consideration. During the first appointment at the practice, we will discuss this and explore how we can support and guide you.

Have you ever had conversations with a social worker/psychologist/psychiatrist? *

If yes, for what issues?

Are you being supported by a helping organization/foundation, such as social work, Stichting Mee, or Youth Care Bureau? *

If yes for what issues?

Have you ever had unpleasant experiences regarding internal examinations or sexual matters? *

Do you think this could have an impact on the pregnancy, childbirth, or the period afterward? *

Have you ever been involved in domestic violence? *

Do you feel you receive enough support from your surroundings? (family, friends, neighbors) *

Are you currently experiencing issues with your partner or family? *

Do you have enough financial resources to care for a child? *

Lifestyle

Do you or did you smoke? *

Enter the number of cigarettes per day or the date you quit

Do you drink alcohol or have you drunk alcohol? *

Do you use drugs? *

If you have used drugs in the past 6 months, please explain which type of drugs

Do you eat vegetarian or vegan? *

Are you on a diet? *

If yes what kind of diet?

Is your partner, for as far as known, healthy? *

Yes
No
Not applicable.

If you have answered this question with 'not applicable,' you can skip all questions regarding the partner.

Explanation of the above question.

Does your partner smoke?

Does your partner drink alcohol

Does your partner use drugs?

Does your partner have medically relevant allergies??

Explanation of the above question.

Hoe uit zich dat?

Does your partner use medicine?

Explanation of the above question., which ones?

Note: If relevant to the pregnancy, please specify dosages.

Is your partner under the care of a psychologist, psychiatrist, or social worker?

Does your partner ever have Cold sores ( Herpes labialis)?

Do the following conditions occur in your family, as far as you know? This refers to the father, mother, brother(s), and sister(s) of the pregnant person.

Clotting disorders such as e.g. thrombosis or Factor V Leiden. *

If the answer is yes, please provide an explanation including who and which disorder.

If yes can you explane?

Diabetes *

If yes,can you explane?

Explanation

High bloodpressure *

If yes please explain

Explanation

Do congenital abnormalities or hereditary diseases occur in the family of you and the (biological) father, as far as you know? *

If yes, please explain

Explanation

Are there any psychological issues in the family? *

Are there people in your first-degree family (parents, brothers, and/or sisters) born with hip dysplasia or other hip abnormalities? *

Menstrual cycle history

What was your first date of your last period?

Was this a normal period? *

Do you have a regular cycle?? *

How many days does your cycle typically last??

If you used contraception before, what did you use and when did you stop?

Did you do a pregnancy test? *

When did you test positive?

Is the pregnancy planed? *

Is the pregnancy desired? *

Obstetric history (if applicable)

Is this your first pregnancy? *

How many children do you have?

How many children do you have out of a previous relationship??

Have you ever had a miscarriage??

If yes, please explain

Explanation? How many miscarriages have you had, and how did it go?

Have you ever had an abortion?

If yes, can you explain?

Were there any complications?

Was this pregnancy spontaneous?? *

If yes, please explain.

If not, what fertility treatment did you receive?

If you already have a child(ren), please answer the following questions..

Who supervised the pregnancy and delivery?

What are the name(s) and birthdate(s) of your child(ren)?

At how many weeks of pregnancy did you give birth?

Where did you give birth?

What was the birth weight of your child(ren)?

Were there any complications during the pregnancy or delivery? (e.g. medication, vacuum extraction, cesarean section, bleeding, difficulties with placenta delivery)

What is not yet aswered

Are there topics we haven't asked about, or important topics that could play a role in the pregnancy, delivery, and/or postpartum period? If so, please explain

Name

Do you agree?

Intake

Partner (indien van toepassing)

PPsychosocial factors

Lifestyle

Menstrual cycle history

Obstetric history (if applicable)

What is not yet aswered

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