Emergency contact: +31 6 532 02 915

Contraception form

  1. First Name(*)
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  2. Surname(*)
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  3. Date of birth(*)
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  4. Address(*)
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  5. Postcode(*)
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  6. City(*)
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  7. Email address(*)
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  8. Phone number during the day(*)
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  9. Mobile phone(*)
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  10. Name of general practitioner(*)
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  11. Height(*)
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  12. Weight(*)
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  13. Citizen’s service number
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  14. What kind of contraception do prefer, and why?(*)
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  15. Which contraception have you used in the past? (explain type of contraception, when and your experience/side effects)(*)
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  16. What are your expectations of your preferred methods and its side effects? (*)
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  17. Cycle

  18. Have you ever given birth?(*)
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  19. If so, have you had your period since the birth?
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  20. If so, what was the first day of your last period?
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  21. Do you value maintaining your menstruation?(*)
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  22. Do you have the desire to have (more) children?(*)
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  23. Health and medical treatments

  24. Are you breastfeeding?(*)
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  25. Do you frequently visit your GP due to your health?(*)
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  26. If yes, why?
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  27. Do you frequently see a specialist in hospital due to your health?(*)
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  28. If yes, why?
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  29. Do you smoke?(*)
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  30. Afflictions

    Have you ever suffered from or have you ever been treated for the following disorders? Please explain if it applies.

  31. Cardiovascular disease(*)
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  32. If yes, explain:
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  33. (gestational) diabetes(*)
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  34. If yes, explain:
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  35. High bloodpressure(*)
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  36. If yes, explain:
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  37. Thrombosis(*)
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  38. If yes, explain:
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  39. Liver problems(*)
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  40. If yes, explain:
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  41. Migraine(*)
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  42. If yes, explain:
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  43. Allergies(*)
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  44. If yes, explain;
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  45. Sexually transmitted disease(*)
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  46. If yes, explain:
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  47. Fibroma or other growths in your uterus?(*)
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  48. If yes, explain:
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  49. Additional questions for intrauterine devices (IUD)

    (You only need to fill out these questions if you choose for an IUD)

  50. Have you ever had a pap smear?
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  51. If so, in what year?
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  52. If so, what was the result?
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  53. Have had a bad experience with internal exams, and/or any bad experiences sexually?
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  54. (*)
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