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Intake form

Intake form

The intake gives us a good picture

During the first consultation with the midwife, we will discuss your health and the health of your (possible) 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 FILLING IN

Gelieve dit veld leeg te laten.

Basic information

Reporting code

Date of birth

Place of birth

Country of birth

Name of GP

Do you speak Dutch?

Menstruationcycle

Date of the first day of the last menstrual period

Cycle duration (number of days):

Date of first positive pregnancy test

What number pregnancy is this for you?

Is this a wanted pregnancy?

NB :

If this is not your first pregnancy, what is/are the birth dates of your other children? If you were
cared for by another midwifery practice during your previous pregnancy(s), would you please request the
information and bring it with you to your intake appointment with us?

Your response

Medical history

Length

Weight (before pregnancy)

Occupation:

You work:

Occupation partner:

Your partner works:

Have you ever had a bladder infection?

Do you ever suffer from gum disease?

Have you ever had a (vaginal) yeast infection?

Have you ever had a cervical smear test?

Have you had chickenpox in the past?

Do you or your partner ever have a cold sore?

Are you at increased risk for MRSA?
(You have an increased risk if you have been admitted to a foreign hospital in the last 3 months....)

Have you ever had a blood transfusion?

Have you ever had thrombosis?

Are you currently taking extra vitamins?

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

Have you ever had surgery?

Have you ever been exposed to 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 sexually transmitted disease?

Are you allergic to anything?

Do you smoke?

Have you ever used drugs?

Did you drink alcohol before pregnancy?

Did you drink alcohol during pregnancy?

Pharmacy name

NB :

Did you answer yes to a question and would you like to expand your question? For example, did you answer
yes
to "Have you ever had surgery?", then tell us when and why you
had surgery.

Your response

Finally, are there any other things we should know about you or your partner that could be important
for this pregnancy?

Family history

Are there any congenital abnormalities or hereditary conditions in your family?

Do your partner's family have any congenital abnormalities or hereditary conditions?

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

Does your immediate family have diabetes? (parents, brothers or sisters, mother in pregnancy)

Are there any special features regarding your partner's health?

Does high blood pressure run in your immediate family?

Are there thyroid disorders in your immediate family?

NB :

Did you answer yes to a question and would you like to expand your question? For example, did you answer
yes
to "Have you ever had surgery?", then tell us when and why you
had surgery.

Your response

Finally, are there any other things we should know about you or your partner that could be important
for this pregnancy?