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PREGNANCY
Birth
Postnatal period
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OUR PRACTICE
- Our team
- What we do
- News
- History
- Fees
- Our privacy policy
- Complaints
PREGNANCY
Birth
Postnatal period
read more
Courses
- Information
- Sign up
Contact

Registration

After registration you will receive an invitation to complete the registration.

Registration form

Your credentials

First name *

Initial(s) *

Last name *

Date of birth *

Country of birth *

Ethnicity *

Do you follow a certain religion? *YesNo

Which religion? *

Should we take this into account? *Yes pleaseNo

How can we take this into account? *

Insurance company *

Policy number *

Citizen service number *

ID number *

Profession *

Employment *

GP *

Address data

Address *

Residence *

Postcode *

Phone number *

Your email address *

Marital status *

Other partnership *

Partner information

First name *

Lastname *

Mobile partner *

Partner's date of birth *

Partner's country of birth *

Partner ethnicity *

Profession partner *

Employment partner *

Questions regarding this pregnancy

Fertility process

We are aware that some people have become pregnant through fertility treatment. In that case, the following questions can be considered not asked (not relevant).

What was (approximately) the first day of your last period?

Was the duration of this period normal?YesNo

Why was the duration not normal

Did this period come on time (on the day you expected it)?YesNo

What did you expect?

Do you normally have regular periods?YesNo

How many days were there between the start of one period and the start of the next period?Between 26-30 daysOtherwiseIrregular

Amount of days

Varying irregularly

Is this a planned pregnancy?YesNo

How long was the period from the moment you wanted to become pregnant until the moment you became pregnant?

Did the pregnancy occur spontaneously or through fertility treatments? *spontaneouslyfertility treatments

Which fertility treatment?

What is the due date based on the fertility treatment? *

If the underlying cause of the fertility problem is known, please mention it here. Consider PCOS, for example.

Have you had your own period at least three times after stopping hormonal contraception (pill, IUD, Nuvaring), a previous pregnancy or miscarriage or after stopping breastfeeding?YesNo

Course of menstruation

When did you take a pregnancy test?

Have you also taken a previous test with a negative result?YesNo

Previous pregnancy(s)

Is this the first time you are pregnant (also give up miscarriage and/or abortion)? *YesNo

Enter the details of previous pregnancies belowSuch as progress, date of birth, child’s name, etc.

Were there any unusual circumstances during the previous pregnancy(s), delivery(s) and/or postpartum(s)?

Are all children healthy now?YesNo

Explanation

Questions regarding your health

How tall are you?in cm

What was your weight before you became pregnant?in kg

Have you ever had any of the following diseases? (check if applicable and explain if necessary) *None of the belowbladder infectionchicken-poxcandida (vaginal fungal infection)blood transfusionthrombosis (or other clotting disorders)cold sorevenereal diseasegingivitisthyroid diseasediabeteslung diseaseliver diseaseheart diseaseepilepsykidney diseasevaricose veins

Do you work in landscaping, with animals or in the meat processing industry? *NoYes

GreeneryWith animalsMeat processing industry

Do you come into close contact with live pigs on pig farms as a professional? *NoYes

Have you ever been admitted to hospital, had surgery, or been treated by a medical specialist? *NoYes

For what and when?

Have you been admitted to a foreign hospital in the past 3 months or have you worked in a foreign hospital in the past 3 months? *NoYes

For what and when?

Do you use medicines and/or vitamin preparations? *NoYes

Which medications?

How often?

Do you use folic acid? *NoYes

Did you start taking folic acid at least 4 weeks before conception?NoYes

Have you ever had a smear test taken for the cervical cancer screening test? *NoYes

When?

What was the outcome?

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

For what and when?

Have you ever had an unpleasant/negative sexual experience? *NoYes

Have you ever been in contact with (domestic) violence? *NoYes

Are you vegetarian/vegan? *VegetarianVeganNo

Are you allergic to anything (medications, latex, plasters, food)? *NoYes

What are you allergic to?

Did you use alcohol before pregnancy? *NoYes

How much per week?

Did you smoke before pregnancy? *NoYes

How much per week?

Did you use drugs (weed, hash, pills/ecstasy, heroin, methadone) before pregnancy? *NoYes

When was the last time?*

Which?

Do you use alcohol during pregnancy? *NoYes

How much per week?

Do you smoke during pregnancy? *NoYes

How much per week?

Do you use drugs (weed, hash, pills/ecstasy, heroin, methadone) during pregnancy? *NoYes

When was the last time?*

Which?

Were you (as a child) vaccinated against rubella? (the vaccination against rubella is part of the standard vaccination program in the Netherlands) *NoYes

Questions regarding your family

The following questions concern the biological father of the child. This could be a partner, a sperm donor, or another person, regardless of the family composition.

In this questionnaire, ‘partner’ generally refers to the partner. If this does not apply, please read the other relevant person.

If you are unsure how to answer the questions below, please discuss this with the midwife during the intake appointment.

Is your partner healthy?YesNo

What health problems are there?

Does your partner smoke?YesNo

Are you and your partner related?YesNo

Does your partner have children from another relationship?YesNo

Has your partner ever had a cold sore?YesNo

Do congenital abnormalities occur in your or the biological father of the child, immediate family (parents, brothers, sisters)? (for example, children with a disability, cleft lip, spina bifida, heart defect, stillbirth or children who died due to an abnormality, chromosomal abnormalities, such as Down syndrome) *YesNoI don’t know

With whom?

What deviation(s) are involved?

Do hereditary diseases or abnormalities run in your or the biological father of the child, family? (e.g. blood diseases/clotting disorders, metabolic diseases, muscle diseases, lung diseases/eczema) *YesNoI don’t know

With whom?

What disease/abnormality is it?

Do the following diseases run in your family (only your parents, brothers, sisters) *None of the belowhigh bloodpressuremother/sister with high blood pressure during pregnancydiabetesthyroid disease

Did your mother or mother of the biological father of the child, have high blood pressure/preeclampsia during pregnancy?YesNoI don’t know

What is it like for you to be pregnant and how do you view the upcoming birth?

Finally, are there any details that may be important for this pregnancy/birth?

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Postnatal period
- What if I don’t have maternity care
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Home
Our team
First appointments
Birth
Postnatal period
- What if I don’t have maternity care
Contact

CONTACT

Phone:
030 231 1376
Urgent:
06 4977 7349
(inh: 085 – 301 83 64)

LOCATIONS

Boothstraat
Boothstraat 5,
3512 BT Utrecht

Gezondheidscentrum Prinsenhof
Eykmanlaan 433,
3571 JR Utrecht

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