Intake form

We consciously do not ask for your name, date of birth or social security number (or your partner's) in this questionnaire in order to guarantee your privacy. Please do state your client number, which you received via email.
It is important to take sufficient time to complete and send this list in one go. Unfortunately there is no option to save it temporarily.

General information

What is your client number?

What is your profession?

How many hours per week do you work?

Do you work with children between the ages of 0-12?
NoYes

What is your nationality?

In what country/ies were your parents born?

Are you religious; if so, what religion?

What is your marital status?
MarriedPartnershipLiving togetherSingleLATOther..

Who is your GP?

What is the name of your pharmacy?

General information of your partner

What is your partner's profession?

How many hours per week does your partner work?

What is your partner's nationality?

In what country/ies were your partner's parents born?

Pregnancy

How many times have you been pregnant?

Did you get pregnant with help (e.g. with medicines or gynecologist)?
NoYes

Did you become pregnant from a donor?
NoYes

[group group_donor_info clear_on_hide]
Can you tell us something about the donor's health (including any hereditary disorders)?

[/group]

What was the first day of your last menstrual period?

What is your average menstrual cycle length in days?

Do you have a regular menstrual cycle?
NoYes

When was your first positive pregnancy test?

Did you use contraception before your pregnancy?
NoYes

[group group_anticonceptie clear_on_hide]
What kind(s) of contraception did you use?

Till when did you use contraception?

[/group]

Medical history of the expectant mother

What is your height (in cm)?

What was your weight before getting pregnant (in kg)?

Could you provide a brief description of your health?

Do you have any birth defects (e.g. heart / extra finger / cleft lip)?

What diseases have you experienced (e.g. heart / lungs / intestines / thyroid)?

Are you being treated by a specialist (now and in the past) and for what?

Do you suffer from clotting problems (e.g. pulmonary embolism / thrombosis)

Do you suffer from varicose veins?
NoYes

What surgeries have you had (if any)?

Have you ever had a blood transfusion?
NoYes

Do you ever suffer from bladder infections?
NoYes

Have you ever suffered from a vaginal yeast infection (Candida)?
NoYes

Have you ever suffered from gum disease?
NoYes

Have you ever had cold sores?
NoYes

Have you (had) a venereal disease and if so, which one?

Have you had a cervical smear test and if so, what and when was the result?

Do you have allergies and if so, which ones?

Did you follow the national vaccination program as a child?
NoYes

Have you experienced the chicken pox?
NoYesUnknown

Do you use folic acid and if so, from when?

Do you take extra vitamin D and if so, from when?

Do you have a possible infection with the MRSA bacteria?
NoYesUnknown

Do you and your baby's biological father have common ancestors?
NoYes

Have you been circumcised?
NoYes

Do or did you smoke?

Do or did you ever drink alcohol?

Do or did you ever use drugs?

Do you take any medications and if so, which ones?

Psycho-social factors of the expectant mother

Have you ever been treated by a psychiatrist or psychologist?
NoYes

Have you ever experienced depressive symptoms?
NoYes

Are you known to Dutch aid agencies (bijv. Wijkteam / JGZ / Consultatiebureau)?
NoYes

Have you experienced domestic violence?
NoYes

Have you ever been a victim of (sexual) abuse?
NoYes

Are you experiencing any financial difficulties?
NoYes

Are there housing problems?
NoYes

Do you have enough support around you (e.g. via family and friends)?
NoYes

Parenthood

Do you already have a child?
NoYes

[group group_parenthood clear_on_hide]
How do you experience parenthood?

Were there any particularities or problems in the first year?

[/group]

Family history (partner)

Could you briefly describe your partner's health?

Does your partner have any birth defects (e.g. heart / extra finger / cleft lip)?

Does your partner suffer from allergies and if so, which ones?

Has your partner ever had cold sores?
NoYes

Does your partner smoke?

Does your partner ever drink alcohol?

Does your partner use drugs?

Does your partner have children from a previous relationship?
NoYes

Family history (at your partner's side)

Are there any birth defects in your partner's family (e.g. heart / extra finger / cleft lip)?

How is your relationship with your partner's parents?

Family history (at the expectant mother's side)

Are there any birth defects in your family (e.g. heart / extra finger / cleft lip)?

Does diabetes run in your family?
NoYes

Are there any relatives with high blood pressure?
NoYes

Are there any relatives with clotting problems (e.g. pulmonary embolism / thrombosis)
NoYes

Do you have thyroid problems in your family?
NoYes

Are there any family members with mental health problems?
NoYes

How is your relationship with your parents?

Previous pregnancies

Have you ever been pregnant before?
NoYes

[group group_prev clear_on_hide]
If you have had previous pregnancy/ies under our practice's care, we may already have most of the data. If you have had your previous pregnancies at other practice(s), we can always request this information with your permission.

Have you ever had a miscarriage or abortion and if so, when was it, how long was the pregnancy and how did it go?

Have you ever given birth before?
NoYes

If so, how did you experience your birth(s)?

[/group]

Submit

You have now completed this form. Thank you!

We now ask you again for your client number for verification. Only fill this in when you have completed the form. This is also to prevent you accidentally sending the form too quickly.