Intake vragenlijst

Personal details

Name*

Voornaam Achternaam

Initials*

initials

Maiden name (if applicable)

Date of Birth*

Address*

Straat + huisnummer Adresregel 2 Stad Staat / provincie / regio Postcode

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?

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 €2000 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

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

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

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

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:

Form 2. Intake vragenlijst

Gegevens zwangere

Werk

Gezondheid

Heeft u op dit moment of in het verleden één van de volgende ziekten/aandoeningen doorgemaakt?

Psychosociale zorg

Familie anamnese

Komen er bij u of bij de aanstaande vader in de familie een van de volgende aandoeningen voor?

Financiën

Verloskundige en gynaecologische voorgeschiedenis

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