Testpagina EN formulieren - Midwives Breedstraat - Utrecht

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Testpagina EN formulieren

Home Testpagina EN formulieren

1. Inschrijfformulier

14%

Your data

Initial(s)*

First Name*

Surname (maiden name / birth name)*

Date of birth*

Are you already known to us in the practice?

Yes

No

Marital status*

Living together

Married

Long distance relationship

Single

Other

Data partner

First Name

Last Name

Address data

Address*

Postal Code*

City*

Contact details

Telephone number

Mobile*

Email address*

Period

1st day of your last period

Cycle

regularly

irregular

Number of days in your cycle

Pregnancy

Have you been pregnant before?

Yes

No

How many pregnancy is this?

How many children do you have?

Particularities

Mothers for Mothers (Moeders voor Moeders)

If you would like more information about Mothers for Mothers, please visit moedersvoormoeders.nl

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2. Uitnodiging versturen

3. Vragenlijst

Pagina 1 van 7

Your data

First Name*

Initial(s)*

Maiden Name*

Date of Birth*

Country of birth*

Ethnicity*

Do you adhere to a particular religion:

Yes

No

Which religion?*

Do we have to take this into account?

Yes please

No not at all

What should we take into account?

Insurance company*

Policy number*

Citizen service number*

ID number*

Profession*

Employment*

General practitioner*

Address data

Address*

Postal Code*

Telephone number

City*

Mobile*

Your email address*

Partner Data

Marital status*

Partner Data

First Name

Last name

Date of birth partner

Country of birth partner

Mobile partner

Ethnicity partner

Profession partner

Employment

Questions regarding this pregnancy

We are aware that some people have become pregnant through a fertility process. 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?

Yes

No, otherwise namely:

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

Yes

No, otherwise namely:

Do you normally have a regular period?

Yes

No

How many days were there between the start of one period and the start of the next period?

At around 28 days, the first day of my period was always the same day

different

irregular

Is this a planned pregnancy?

Yes

No

How long was the period from the moment you had a pregnancy wish to the moment you were pregnant?

Did the pregnancy come about spontaneously or through fertility treatments?

spontaneous

fertility 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. For example, consider PCOS'

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?

Yes

No

When did you take a pregnancy test?

Have you also done a previous test with a negative result?

Is this the first time you are pregnant (including miscarriage and / or abortion)?*

Yes

No

Questions regarding previous pregnancy (s)

Fill in the details of the previous pregnancies below

Such as expiration, date of birth, name of baby, etc.

Were there any particularities during the previous pregnancy(s), delivery(s) and/or maternity bed(s)?

Are all children healthy now?

Yes

No

Explanation

Questions regarding your health

How tall are you?

What was your weight before you got pregnant?

Have you ever had any of the following illnesses? (tick if applicable and explain if necessary)

bladder infection

candida (vaginal yeast infection)

operation

blood transfusion

thrombosis (or other clotting disorders)

cold sores

venereal disease

gum disease

thyroid disease

diabetes mellitus

lung disease

liver disease

heart disease

epilepsy

kidney disease

varicose veins

chicken-pox

Explenation

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

No

Yes

Landscaping

With animals

Meat processing industry

Do you come into close professional contact with live pigs on pig farms?

No

Yes

Have you ever been hospitalized, operated on, or treated by a medical specialist?

No

Yes

For what?

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?

No

Yes

For what?

When?*

Do you use medicines and/or vitamin preparations?

No

Yes

Which?

How often?

Do you use folic acid?

No

Yes

From when?

Have you ever had a smear taken for the cervical cancer screening programme?

No

Yes

When?*

What was the result?

Have you ever been treated by a psychologist or psychiatrist?

No

Yes

For what?

When?*

Have you ever been in contact with sexual violence?

No

Yes

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

No

Yes

Are you vegetarian/vegan?

No

Vegetarian

Vegan

Are you allergic to something (medicines, latex, plasters, food)?

No

Yes

What are you allergic to?

Did you use alcohol before pregnancy?

No

Yes

How much a week?

Did you smoke before pregnancy?

No

Yes

How much per day?

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

No

Yes

When was the last time?*

Which?

Do you use alcohol during pregnancy?

nee

ja

How much a week?

Do you smoke during pregnancy?

nee

ja

How much per day?

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

nee

ja

When was the last time? When was the last time?*

Which?

Were you (as a child) vaccinated against rubella?

No

Yes

Questions about your family

Is your partner healthy?

Yes

No

Does your partner smoke?

Yes

No

Are you and your partner related?

Yes

No

Does your partner have children from another relationship?

Yes

No

Has your partner ever had cold sores?

Yes

No

Are there any birth defects in your or your partner's 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 for example Down syndrome)

Yes

No

With whom?

Which deviation(s) are involved?

Are there any hereditary diseases or abnormalities in your or your partner's family? (e.g. blood diseases/clotting disorders, metabolic diseases, muscle diseases, lung diseases/eczema)

Yes

No

With whom?

What disease/disorder is it?

Do the following diseases run in your family (only your parents, brothers, sisters)

high bloodpressure

mother/sister with high blood pressure during pregnancy

diabetes mellitus

thyroid disease

Did your mother or your partner's mother have high blood pressure / preeclampsia during pregnancy?

Yes

No

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

Finally, are there any other details that could be important for this pregnancy/delivery?

Particularities ...

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Welcome
THE CORONAVIRUS
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Trying to conceive
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When to call?
Labour
Practical
Contact

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Boothstraat
Boothstraat 5, 3512 BT Utrecht

Healthcentre Prinsenhof
Eykmanlaan 433, 3571 JR Utrecht

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CONTACT

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In case of emergencies: 06 4977 7349
(bgg: 0900-1515)

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Midwifery Practice Breedstraat