Questionnaire

Congratulations on your pregnancy! You have your intake with one of the midwifes of Vida soon. We want to take care of you in the best way possible, so we'd like to ask you some questions. The questions are about your health and your family.

The form contains 8 sections: personal data, general, nutrition, health, obstetric history, family, work and partner.

At the end of the form you can aks questions or put comments. Good luck with the filling out!

Personal
1a. What is your height?*
1b. What is your weight?*
2. Are you, and/or are your parents or grandparents originally from (multiple options possible):*
- North Africa (Morocco, Tunis, Libya and Egypt)
- Eastern Mediterranean countries (Israel, Palestine, Jordan, Syria, Turkey, Cyprus and Malta)
- Antillen, Aruba or Suriname (also combinations of African/Creole/Chinese/Hindu/Portuguese)
- Cape Verde
- One of the Central African states or one of the Arab Emirates
- Southern Europe (Portugal, Spain, Southern France, Italy, Greece, Albania, Romania, Bulgaria, and the new states of former Yugoslavia
- Middle and Eastern Asia (Pakistan, India, Bangladesh, Myanmar, Thailand, Indonesia, and China)
- Middle East (Iran, Iraq, Afghanistan and the Kurdish regions)
- None of the above

nutrition
3. Are you currently using folic acid?*
If you are not yet 10 weeks pregnant, it is wise to start taking folic acid as a supplement. This will help to decrease the risk of congenital malformations of the baby. You can buy folic acid supplements at the pharmacy or drug store.
- Yes, I started it before I got pregnant
- Yes, I started as soon I found out that I am pregnant
- No
4. Do you have an alternative nutrition pattern?*
- Vegetarian (no meat, no fish)
- Vegan (no animal products)
- Weight loss diet
- Diet as advised by a doctor
- None of above

Health
5. Are you healthy or do you visit your general practitioner on a regular basis*
- I am healthy
- I visit my general practitioner on a regular basis
I visti my general practitioner because:
6. Are you using any type of medication?*
- No
- Yes
Write down the name(s) of the medication and the dose per day that you are using.
7. Do you have any allergies?*
- No
- Yes
What allergies do you have?
8. Do you have or have you ever had any of the following diseases, which required treatment by a doctor? (multiple answers possible)*
- Asthma or another type of lung disease
- Autoimmune disease (a disease where your body creates antidotes against the body's own proteins)
- Problems concerning blood coagulation
- Epilepsy
- Heart disease
- High blood pressure
- Psychological complaints (such as feeling down/depression, anxiety, panic, mental confusion/psychosis, addictive behavior and/or personality disorder)
- Thyroid malfunction/disease
- Sickle cell disease
- Diabetes Mellitus type 1 or type 2
- Thalasemia
- Thrombosis (leg), pulmonary embolism, stroke (TIA/CVA)
- Any other chronic or congenital disease
- None of the above
What chronic or congenital disease?
9. Have you ever received treatment from a specialist?*
- No
- Yes
Explain question 9:
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Year Specialist Hospital Reason Treatment
10. Have you ever been operated?*
- No
- Yes
Explain:
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Year Specialist Hospital Reason Narcosis yes/no
11. Have you ever had, or currently have, any of the sexual transmitted diseases as listed below?*
- Hepatitis B (infection of the liver)
- Genital herpes
- Chlamydia
- Genital warts
- Gonorrhea
- Syphylis (lues)
- HIV/Aids
- Trichomonas
- None of the above
12. Have you ever had a PAP Smear taken for cervical cancer screening?*
- No
- Yes
When and what was the result?
13. Do you often suffer from cystitis?*
- Sporadic
- 1-2 times a year
- More often than twice a year
- Never
14. Do you often suffer from candida infrection?*
- Sporadic
- 1-2 times a year
- More often than twice a year
- Never
15. Have you been vaccinated against Rubella as a child (at 14 months and 9 years old?) or have you had this disease?*
- Yes
- No
16. Have you ever had the disease called Varicella (chicken pox)?*
- Yes
- No
17. Do you ever suffer from the herpes simplex virus (cold sores)*
- Yes
- No

Obstetric history
18. Have you been pregnant before (including miscarriages and/or abortions)?*
- Yes
- No
This is my <choose below> pregenancy:
19. Have you ever had a miscarriage and/or an abortion?
- Yes
- No
When was this?
20. Do you have children?
Anwer 'no' if you have never given labour. If you have given labour, even if it didn't end well, please answer 'yes'. You can explain later.

This question includes all children, if they're still alive or not.
- Yes
- No
If, during previous pregnancies, you have not received your perinatal care from us, we would like you to fill out the information as asked below
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Name of the child Date of birth Duration of pregnancy Weight of the baby at birth At home/In the hospital
21. During previous pregnancies, have you gone through any of the following diseases?
- Pregnancy induced diabetes (diabetes gravidarum)
- High blood pressure
- Any other severe complication related to your pregnancy
What other disease/complication?
22. Were there any deviant details during (one of) your previous labour(s)?
- Caesarean Section
- Abnormally high amount of vaginal blood loss
- Placenta was not born spontaneously
- Vaginal rupture that had to be sutured (stitched) under full anesthesia
- Something else
- No
What other deviant detail(s)?
23. Were there any deviant details during your postnatal period?
- Yes
- No
What details?
24. Have you breastfed your previous child(eren)?
- Yes
- No
For how long did you breastfeed?
25. Is your child/are your children healthy now?
- Yes
- No
Explain:

Work
28. What is your profession / what do you do for a living??*
29. While working, I am regularly in contact with:*
- Ill and/or small children
- Bodily tremors, high air pressure, extreme temperatures, noise > 80 decibel
- Chemical products (solvents, pesticides, anesthetic gases, medicines against cancer or heavy metals such as mercury, lead or cadmium)
- None of the above
30. Are you working in shifts, nightshift and/or are you working irregular hours*
- Yes
- No

Consent data processing*
To be able to process this questionnaire we have to process the provided data in the form. We are very careful with your data as explained in our privacy statement.
- I give permission to process this data
Almost finished! If you have some questions or comments, you can leave them below. If not, press 'Send'.
Comments
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General

Personal

nutrition

Health

Obstetric history

Familiy

Work

Consent form

Name of the child	Date of birth	Duration of pregnancy	Weight of the baby at birth	At home/In the hospital

Year	Specialist	Hospital	Reason	Treatment

Year	Specialist	Hospital	Reason	Narcosis yes/no