Emergency contact: +31 6 532 02 915

Intake

During our intake meeting we would like to get to know you and your partner better. That’s why we request that you, in preparation of this meeting, fill out the form below. The questions regard your health and any illnesses and (congenital) abnormalities that may occur within you, your partner and immediate family. With this information we will judge whether there are aspects that we need to take extra care of during the pregnancy, childbirth and/or postpartum period.

During our intake meeting we’ll look at the questionnaire together. Your information will be treated and stored carefully. We comply with the applicable legal privacy regulations.

Intake form
  1. Personal details

  2. Name(*)
    Ongeldige invoer
  3. Date of birth(*)

    Ongeldige invoer
  4. Address(*)
    Ongeldige invoer
  5. Postcode(*)
    Ongeldige invoer
  6. City(*)
    Ongeldige invoer
  7. Phone number(*)
    Ongeldige invoer
  8. Mobile number(*)
    Ongeldige invoer
  9. Email address(*)
    Ongeldige invoer
  10. Citizen’s service number(*)
    Ongeldige invoer
  11. Insurer(*)
    Ongeldige invoer
  12. Insurance number(*)
    Ongeldige invoer
  13. General Practitioner(*)
    Ongeldige invoer
  14. Marital state(*)
    Ongeldige invoer
  15. Country of birth(*)
    Ongeldige invoer
  16. Country of birth of your mother(*)
    Ongeldige invoer
  17. Country of birth of your father(*)
    Ongeldige invoer
  18. What is your living situation?(*)
    Ongeldige invoer
  19. What is your highest level of education?(*)
    Ongeldige invoer
  20. Do you have good (Dutch) reading and writing skills?(*)
    Ongeldige invoer
  21. Do you speak Dutch?(*)
    Ongeldige invoer
  22. Are you adhering to a belief?(*)
    Ongeldige invoer
  23. Do you work? (voluntarily or paid)(*)
    Ongeldige invoer
  24. How many hours a week?
    Ongeldige invoer
  25. What kind of work do you do?
    Ongeldige invoer
  26. Is your occupation stressful or do you stand a lot during the day?(*)
    Ongeldige invoer
  27. Do you get in touch with chemicals or radiation? (*)
    Ongeldige invoer
  28. Do you work with young children?
    Ongeldige invoer
  29. Do you have difficult debt repayments, do you have a debt repayment?(*)
    Ongeldige invoer
  30. Partner (if applicable)

  31. Name partner
    Ongeldige invoer
  32. Phone number partner:
    Ongeldige invoer
  33. E-mailadres partner:
    Ongeldige invoer
  34. Date of birth partner

    Ongeldige invoer
  35. Highest level of education?
    Ongeldige invoer
  36. Do you work? If yes, what is your occupation? Do you get in touch with chemicals?
    Ongeldige invoer
  37. Country of birth
    Ongeldige invoer
  38. Do you have children from a previous relationship?
    Ongeldige invoer
  39. If yes, do your children have health problems?
    Ongeldige invoer
  1. General health and medication

  2. Please state in your explanation what illness is involved, in which year this took place, which treatment you have undergone and what the result was.

  3. What is your height? (cm)(*)
    Ongeldige invoer
  4. What was your weight before the pregnancy (kg)?(*)
    Ongeldige invoer
  5. Do you regularly go to the doctor?
    Ongeldige invoer
  6. If yes, why?
    Ongeldige invoer
  7. How is your general health?
    Ongeldige invoer
  8. Have you ever undergone surgery? (*)
    Ongeldige invoer
  9. If yes, in what year and what kind of surgery?
    Ongeldige invoer
  10. Did you ever have a transfusion of blood or blood products?(*)
    Ongeldige invoer
  11. If yes, in what year and why?
    Ongeldige invoer
  12. Are you aware of any medically relevant allergies? E.g. band aids, medicine, latex, iodine?(*)
    Ongeldige invoer
  13. If yes, what kind of allergy?
    Ongeldige invoer
  14. Have you ever suffered from cold sores ( Herpes labialis)?(*)
    Ongeldige invoer
  15. Have you ever had a bladder infection? (*)
    Ongeldige invoer
  16. Have you ever had a vaginal fungal infection (candida)?(*)
    Ongeldige invoer
  17. Have you ever had gingivitis?(*)
    Ongeldige invoer
  18. Do you take folic acid or multivitamin supplements specifically for during a pregnancy?(*)
    Ongeldige invoer
  19. If you don’t use folic acid at this moment, we advise to immeditaly start using 0,4/0,5mg of folic acid daily. Folic acid is important for the development of your baby. It decreases the chance of spina bifida and cleft lip/palate.

  20. When did you start using folic acid or multivitamin supplements?(*)
    Ongeldige invoer
  21. Do you currently use any medication?(*)
    Ongeldige invoer
  22. What medications do you use?
    Ongeldige invoer
  23. Name of the medication
    Ongeldige invoer
  24. Do you (frequently) visit a specialist in hospital due to your health?(*)
    Ongeldige invoer
  25. If yes, due to which affliction or disease?
    Ongeldige invoer
  26. Have you ever had a pap smear?(*)
    Ongeldige invoer
  27. When? What was the result?
    Ongeldige invoer
  28. Have you even been treated for sexual transmitted disease? (STD)?(*)
    Ongeldige invoer
  29. If yes, which STD?
    Ongeldige invoer
  30. Have you received your vaccinations as per the Dutch vaccination program, as a child?(*)
    Ongeldige invoer
  31. Have you ever had chickenpox?(*)
    Ongeldige invoer
  32. Have you been admitted to a foreign hospital in the past 6 months?(*)
    Ongeldige invoer
  33. Do you work professionally with pigs, calves or broilers?(*)
    Ongeldige invoer
  34. Psychosocial factors

  35. We pose these last four questions because these topics may influence your experience of the pregnancy, childbirth or postpartum period. We prefer being informed so we can best guide you. During our first meeting at the practice we will discuss these matters and how we can best support and guide you.

  36. Have you ever had conversations with a social worker, psychologist and/or psychiatrist?(*)
    Ongeldige invoer
  37. When and how long?
    Ongeldige invoer
  38. Do you receive guidance from a assisting authoratie, as social worker, child protecting services?(*)
    Ongeldige invoer
  39. If yes, because of what issues?
    Ongeldige invoer
  40. Have you ever had a bad experience with internal exams, and/or any bad experiences sexually?(*)
    Ongeldige invoer
  41. Do you think this may affect the pregnancy, childbirth or postpartum period?(*)
    Ongeldige invoer
  42. Have you ever experienced domestic abuse?(*)
    Ongeldige invoer
  43. Do you experience good social support from your family and friends?(*)
    Ongeldige invoer
  44. Do you have any problems with your family or friends at this moment?(*)
    Ongeldige invoer
  45. Do you have sufficient financial means to take care of a child?(*)
    Ongeldige invoer
  46. Information regarding lifestyle and intoxications

  47. Do or did you smoke?(*)
    Ongeldige invoer
  48. If yes, specify the amount per day / when you stopped smoking
    Ongeldige invoer
  49. Do or did you drink alcohol? And did you have any alcohol during this pregnancy?(*)
    Ongeldige invoer
  50. Have you used drugs in the past 6 months?(*)
    Ongeldige invoer
  51. If you used drugs in the past 6 months, please write down when and what :
    Ongeldige invoer
  52. Are you a vegetarian or vegan?(*)
    Ongeldige invoer
  53. Do you use a diet?(*)
    Ongeldige invoer
  54. If yes, which diet?
    Ongeldige invoer
  1. Health of your partner and family members

  2. Is your partner, for as far as known, healthy?
    Ongeldige invoer
  3. If no, what disease does he suffer from?
    Ongeldige invoer
  4. Does you partner smoke?
    Ongeldige invoer
  5. Does your partner drink alcohol?
    Ongeldige invoer
  6. Does your partner use drugs?
    Ongeldige invoer
  7. Does your partner have allergies?
    Ongeldige invoer
  8. Which allergies?
    Ongeldige invoer
  9. Does your partner use any medication?
    Ongeldige invoer
  10. Is your partner being guided by a psychologist, psychiatrist or social worker?
    Ongeldige invoer
  11. Does your partner have ever suffered from cold sores ( Herpes labialis)?? (*)
    Ongeldige invoer
  12. Do the following afflictions occur in your family members? This regards the father, mother, brothers and sisters of the pregnant woman.

  13. Diabetes:(*)
    Ongeldige invoer
  14. If yes, which type?
    Ongeldige invoer
  15. High blood pressure:(*)
    Ongeldige invoer
  16. If yes, explain
    Ongeldige invoer
  17. Eleborate thyroid issues(*)
    Ongeldige invoer
  18. If yes, explain
    Ongeldige invoer
  19. Do any congenital abnormalities or hereditary diseases occur within your immediate family or the family of the biological father?(*)
    Ongeldige invoer
    Think of congenital heart diseases, spina bifida, cleft lift, lap foot or other congenital abnormalities.
  20. Which abnormality or disease and with who?
    Ongeldige invoer
  21. Do psychological problems occur in your family?(*)
    Ongeldige invoer
  22. Is someon of your immediate family (parents, brothers and / or sisters) born with hip dysplasia or other hip abnormalities?(*)
    Ongeldige invoer
  23. Questions about your menstrual cycle

  24. What was the first day of your last menstrual period?(*)
    Ongeldige invoer
  25. Was this a normal menstrual period for you?(*)
    Ongeldige invoer
  26. Is your menstrual cycle regular?(*)
    Ongeldige invoer
  27. What’s is the average number of days of your cycle?(*)
    Ongeldige invoer
  28. If you used birth control before, what did you use and when did you and when did you stop using it?
    Ongeldige invoer
  29. Did you do a pregnancy test?(*)
    Ongeldige invoer
  30. If yes, when did it test positive
    Ongeldige invoer
  31. Is this pregnancy planned?(*)
    Ongeldige invoer
  32. Is this pregnancy wanted?(*)
    Ongeldige invoer
  33. Previous pregnancies (if applicable)

  34. Is this your first pregnancy?
    Ongeldige invoer
  35. If not, which number of pregnancy is this?
    Ongeldige invoer
  36. Do you have children from a previous relationship?
    Ongeldige invoer
  37. Have you ever have a miscarriage?
    Ongeldige invoer
  38. If yes, how many? Did any complications occur?
    Ongeldige invoer
  39. Have you ever had an abortion?
    Ongeldige invoer
  40. If yes, when ? Did any complicaties occur?
    Ongeldige invoer
  41. Is this a spontaneous pregnancy?
    Ongeldige invoer
  42. If not, what fertility treatment did you get?
    Ongeldige invoer
  43. If you already have a child/children, please answer the following questions.

  44. Who guided your pregnancy and delivery?
    Ongeldige invoer
  45. Name and birthdates of you child(ren)
    Ongeldige invoer
  46. At what term did you gave birth?
    Ongeldige invoer
  47. Where did you give birth?
    Ongeldige invoer
  48. Birthweights of your child(ren):
    Ongeldige invoer
  49. Where there any particularities during the pregnancy or delivery? (e.g. medication, cesarean section, excessive bloodloss, problems during the afterbirth)
    Ongeldige invoer
  50. Other

  51. Is there anything that was missing on this form that may be important to you or may contribute significantly to your pregnancy, childbirth or postpartum period?
    Ongeldige invoer
  52. (*)
    Ongeldige invoer
  53. Submit

cooperatieverloskundigen    icoon2    knov