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

  • Employment

  • Health

  • 1 glass of wine = 3 units. 1 beer = 1 unit.
  • 1 beer = 1 unit. 1 glass of wine = 3 units
    (German measles)
    (Varicella)
  • Are you suffering from or have you ever suffered from any of the following medical conditions?

    Urine infection
    Vaginal yeast infection
    Gingivitis
    Heart and circulatory problems
    Hospital consultant
  • Month-Year
    Blood relation
  • Psycho-social care

  • Family history

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

    Thalassemia/Sickle-cell disease
    Schisis
  • Finances

  • Obstetric and gynaecological history

  • If no, scroll to the next section

  • Date Format: DD dash MM dash YYYY
    1st child
  • Weeks...days...(eg. 40 weeks, 3 days)
  • 1st child
  • 1st child (grams)
  • 1st child
  • 1st child
  • Date Format: DD dash MM dash YYYY
    2nd child
  • 2nd child
  • Weeks...days...(eg. 40 weeks, 3 days)
    2nd child
  • 2nd child
  • 2nd child (grams)
  • 2nd child
  • 2nd child
  • Date Format: DD dash MM dash YYYY
    3rd child
  • Weeks...days...(eg. 40 weeks, 3 days)
  • 3rd child
  • 3rd child (grams)
  • 3rd child
  • 3rd child
  • Date Format: DD dash MM dash YYYY
    4th child
  • Weeks...days...(eg. 40 weeks, 3 days)
  • 4th child
  • 4th child (grams)
  • 4th child
  • 4th child