Intake questionnaire

Important!

For your registration with Verloskundig Centrum DelVi we need a number of personal details from you. Due to the integrated care model and close working relationship with the Reinier de Graaf hospital, this questionnaire is extensive.
Completing the form will take approximately 10-15 minutes.
It is very important that you complete the form as fully as possible.

If any of the questions are unclear, please contact us or ask us during your first appointment.

Form 2. Intake questionnaire

Personal details
Name*
First Last
Initials*
initials
Maiden name (if applicable)
Date of Birth*

Day
Month
Year
Address*
Street Address Address Line 2 City County / State / Region ZIP / Postal Code
Burgerservicenummer (BSN)*
Phone number*
Employment
Do you have a job where you have to stand for long periods of time?
- No
- Yes
Do you work with little children?
- No
- Yes
Do you work unsocial hours or night shifts?
- No
- Yes
Are you at risk of exposure to radiaoctive substances or ionising radiation?
- No
- Yes
Health
Are you taking Folic Acid?
- Yes
- No
Are you taking pregnancy vitamins?
- Yes
- No
Do you smoke?
- No
- Yes
If yes, how many cigarettes per day BEFORE the pregnancy?
If yes, how many cigarettes per day DURING the pregnancy?
Do you drink alcohol?
- No
- Yes
If yes, how many units per day BEFORE the pregnancy?

1 glass of wine = 3 units. 1 beer = 1 unit.
If yes, how many units per day DURING the pregnancy?

1 beer = 1 unit. 1 glass of wine = 3 units
Do you use drugs?
- No
- Yes
If yes, what drugs do you use?
If yes, how often per week BEFORE the pregnancy?
If yes, how often per week DURING the pregnancy?
Do you take any medication?
- No
- Yes
If yes, what medication do you take?
Since when?
What is the dosage?
Do you eat fresh fruit and vegetables every day?
- Yes
- No
Do you follow a special diet?
- No
- Vegetarian
- Vegan
- Macrobiotic
Are you in good health?
- Yes
- No
Have you been vaccinated against Rubella?
- Yes
- No
(German measles)
Have you had Chicken Pox or been vaccinated against Chicken Pox?
- Yes
- No
(Varicella)
Have you ever had a blood transfusion?
- No
- Yes
Have you been treated in or admitted to a hospital in a foreign country within the last two months?
- No
- Yes
Are you suffering from or have you ever suffered from any of the following medical conditions?
Cystitis
- No
- Yes
Urine infection
If yes, how often?
- Sporadic
- 1-2 x per year
- More than 2 x per year
Candida
- No
- Yes
Vaginal yeast infection
If yes, how often?
- Sporadic
- 1-2 x per year
- More than 2 x per year
Infection in gums
- No
- Yes
Gingivitis
Allergies
- No
- Yes
If yes, what allergies to you have?
Cold sores
- No
- Yes
Diabetes
- No
- Yes
Thrombosis
- No
- Yes
Do you bruise easily or do wounds take a long time to stop bleeding?
- No
- Yes
Cardio-vascular disease
- No
- Yes
Heart and circulatory problems
Liver or kidney disease
- No
- Yes
Epilepsy
- No
- Yes
Cancer
- No
- Yes
Asthma/chronic bronchitis (COPD)
- No
- Yes
Rheumatism
- No
- Yes
Eating disorders
- No
- Yes
Are you being (or have been) treated by a medical specialist?
- No
- Yes
Hospital consultant
If yes, which specialist?
If yes, which hospital?
When?

Month-Year
What are/were you being treated for?
Have you every had any surgery?
- No
- Yes
If yes, which specialist carried out the surgery?
In which hospital?
When?
What type of surgery?
Please detail any further procedures/surgeries?
Are you related to the father of the baby?
- No
- Yes
Blood relation
If yes, please explain how you are related:
Do you have any hereditary disease(s)?
- No
- Yes
If yes, please provide details:
Psycho-social care
Have you ever had contact with:
- A social worker
- A psychologist
- A psychiatrist
- Child support services
If yes, when?
If yes, what was the reason?
Have you every used psychiatric medication?
- No
- Yes
If yes, which medication?
When?
For how long?
Do you have enough support around you?
- Yes
- No
Have you ever been abused?
- No
- Yes
Have you ever been a witness of abuse?
- No
- Yes
Have you ever been a victim of sexual abuse?
- No
- Yes
Have you had a negative experience with a health care worker/carer?
- No
- Yes
Family history
Is your partner in good health?
- Yes
- No
If no, please provide further details:
Does your partner smoke?
- No
- Yes
If yes, does your partner smoke in the house?
- No
- Yes
Does your partner ever suffer from cold sores?
- No
- Yes
Does your partner have a hereditary disease?
- No
- Yes
If yes, please provide further details:
Does anyone in your family or in your partner's family suffer from any of the following diseases:
High blood pressure
- No
- Yes
If yes, by whom?
Diabetes
- No
- Yes
If yes, by whom?
Hereditary anaemia
- No
- Yes
Thalassemia/Sickle-cell disease
If yes, by whom?
Clotting disorder/haemophilia
- No
- Yes
If yes, by whom?
Congenital blindness or poor vision
- No
- Yes
If yes, by whom?
Congenital deafness
- No
- Yes
If yes, by whom?
Heart defects
- No
- Yes
If yes, by whom?
Diseases of the central nervous system
- No
- Yes
If yes, by whom?
Hip defects
- No
- Yes
If yes, by whom?
Muscular diseases
- No
- Yes
If yes, by whom?
Cleft lip or cleft palate?
- No
- Yes
Schisis
If yes, by whom?
Spina bifida, anencephaly or hydrocephaly?
- No
- Yes
If yes, by whom?
Down's Syndrome
- No
- Yes
If yes, by whom?
Mental retardation (eg. Fragile X syndrome)
- No
- Yes
If yes, by whom?
Any other hereditary or congenital defects?
- No
- Yes
If yes, please provide details:
Finances
Do you and/or your partner combined earn less than €1000 per month?
- No
- Yes
Are you experiencing financial difficulties?
- No
- Yes
If yes, do you have help to deal with these difficulties?
- No
- Yes
- n/a
Obstetric and gynaecological history
Do you have children?
- No
- Yes
If no, scroll to the next section
Date of Birth
DD dash MM dash YYYY

1st child
Where was he/she born?
How far pregnant were you when you gave birth?

Weeks...days...(eg. 40 weeks, 3 days)
Sex
- Boy
- Girl
Name
First Middle Last
1st child
Birth weight

1st child (grams)
Type of birth

1st child
Further details/complications?
1st child
Date of Birth
DD dash MM dash YYYY

2nd child
Where was he/she born?

2nd child
How far pregnant were you when you gave birth?

Weeks...days...(eg. 40 weeks, 3 days)
Sex
- Boy
- Girl
2nd child
Name
First Middle Last
2nd child
Birth weight

2nd child (grams)
Type of birth

2nd child
Further details/complications?
2nd child
Date of Birth
DD dash MM dash YYYY

3rd child
Where was he/she born?
How far pregnant were you when you gave birth?

Weeks...days...(eg. 40 weeks, 3 days)
Sex
- Boy
- Girl
Name
First Middle Last
3rd child
Birth weight

3rd child (grams)
Type of birth

3rd child
Further details/complications?
3rd child
Date of Birth
DD dash MM dash YYYY

4th child
Where was he/she born?
How far pregnant were you when you gave birth?

Weeks...days...(eg. 40 weeks, 3 days)
Sex
- Boy
- Girl
Name
First Middle Last
4th child
Birth weight

4th child (grams)
Type of birth

4th child
Further details/complications?
4th child
Do you have a child with a congenital defect?
- No
- Yes
If yes, please provide more details:
Do you have one (or more) child(ren) under the care of a paediatrician?
- No
- Yes
If yes, under which specialist?
If yes, please provide further details:
Do you have any children who don't live with you?
- No
- Yes
If yes, what is the reason?
Have you experienced problems with any of your children with regard to health, child support services or parenting?
- No
- Yes
If yes, please provide more details:
Have you ever had a miscarriage?
- No
- Yes
If yes, how many?
Have you ever had an ectopic pregnancy?
- No
- Yes
Have you ever been diagnosed with an abnormality of your cervix or uterus?
- No
- Yes
If yes, please provide further details:
Have you ever had a cervical smear test?
- No
- Yes
If yes, when?
What was the result?
Have you ever had a sexually transmitted disease?
- No
- Yes
If yes, what was it?
Who was it treated by?
Have you been circumcised?
- No
- Yes
Please provide any further information/questions:

Important!

Form 2. Intake questionnaire

Personal details

Employment

Health

Are you suffering from or have you ever suffered from any of the following medical conditions?

Psycho-social care

Family history

Does anyone in your family or in your partner's family suffer from any of the following diseases:

Finances

Obstetric and gynaecological history

If no, scroll to the next section