intake form - Verloskundigenpraktijk Onder de Linde

Homeintake form

The intake gives us a good picture

During the first meeting with the midwife, we will discuss your health and the health of your (eventual) partner. By completing the intake form before you come to this first appointment, we can already form a good picture of how we can provide you with the best care.

HELP WITH COMPLETING

Laat dit veld leeg.

Basic information

Report code

Birthdate

Birthplace

Country of Birth

General Practioner

Do you speak dutch?

Menstrual cycle

First day of your last period

Duration cycle (in days):

Date first positive pregnancy test

How many pregnancies did you have?

Is this a wanted pregnancy?

Notice :

If it's not your first pregnancy, what are the birthdates of your other children? If the other pregnancies are with another midwifery practice, can you take the data to your first appointment?

Your response

Medical history

Height

Weight (before pregnancy)

Profession:

Employment:

Profession partner:

Employment partner:

Did you ever had an cystitis?

Did you ever had gingivitis?

Did you ever had a candida infection (vaginal yeast)?

Did you ever had a papsmear?

Did have you had chicken-pox in the past?

Did you or your partner ever had a cold soar?

Do you have a high risk for MRSA? (You have a high risk if you were hospitalized in a foreign hospital in the past 3 months....)

Did you ever had a blood transfusion?

Did you ever had thrombosis?

Do you take extra vitamins?

Are you currently taking any medication? Has this been discussed with a doctor?

Did you ever have any surgery?

Have you ever been in contact with violence?

Have you ever been treated by a psychologist or psychiatrist?

Have you ever been treated by a doctor or specialist?

Have you ever had a sexual disease?

Do you have any allergies?

Do you smoke?

Have you ever had drugs (in the past 6 months)?

Did you drink alcohol before pregnancy?

Did you drink alcohol in pregnancy?

Notice :

Did you answer yes to a question and do you want to expand your question? Eg. if you answered yes to "Have you ever had surgery?", tell us when and why you had surgery.

Your response

Family history

Do you have any congenital abnormalities or hereditary disorders in your family?

Are there any congenital abnormalities or hereditary disorders in your partner's family?

Have you been in contact with someone with open TB (tuberculosis) in the last six months?

Does diabetes run in your immediate family? (parents, siblings, pregnant mother)

Are there particularities in the health of your partner?

Have any of your direct family high blood pressure?

Have any of your direct family thyroid abnormalities?

Notice :

Did you answer yes to a question and do you want to expand your answer?

Your response

Finally, is there anything else we should know about you or your partner that could be important for this pregnancy?

I and my partner agree to the privacy policy of Praktijk Onder de Linde and consent to the processing of our data.