Questionnaire

When you have your first check-up we will be conducting a detailed history. This is why we ask you to fill out the questionnaire below. This way you can prepare for the questions and you can try to find out the things you don’t know already.

The filling out of the questionnaire can be done in two ways:

Download the questionnaire as a pdf and bring this to your intake (this form is in Dutch, if you prefer the English version you can click on the link below)
Fill out the questionnaire by clicking on the link below. You don’t have to bring the document to your intake

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.

Step 1 of 9

11%

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!

General
Initials*
First name*
Maiden name (surname)*
The last name you got when you were born
Date of birth*
Phone Number*
Email*
Marital status*
- Married
- Registered partnership
- Living together without a registered partnership
- In a relationship without living together
- Divorced
- Single
General practicioner*
Insurance*
BSN (Dutch ID-number)*
How did you find us
- Internet
- General practicioner
- Phone book
- Via via
Do you have a partner?*
- Yes
- No
Last name (partner)
First name (partner)
Date of birth (partner)
Telephone number (partner)

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:

Add new rows with the + sign
(The input rows are small, so not all your text will be visible in the form)

Year	Specialist	Hospital	Reason	Treatment

10. Have you ever been operated?*
- No
- Yes

Explain:

Add new rows with the + sign
(The input rows are small, so not all your text will be visible in the form)

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

Add new rows with the + sign
(The input rows are small, so not all your text will be visible in the form)

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:

Familiy
26.Have any of your direct family members been born with any congenital diseases / handicaps?*
- Yes
- No
- I don't know
What congenital diseases?
- Diabetes
- Thrombosis and/or blood vessel diseases
- Congenital heart disease
- Clubfeet
- Open tummy
- Congenital kidney malfunctions
- Cleft lip and/or palate
- Spina Bifida (split spine), cleft skull or hydrocephalus
- Hemophilia (hereditary coagulation disorder) or carrier of the Hemophilia gene
- Sickle Cell disease (hereditary anemia) or carrier of the Sickle Cell gene
- Muscular diseases, i.e. Duchenne Disease
- Cystic Fibrosis (CF) or carrier of the CF gene
- Thalassemia (hereditary anemia) or carrier of the Thalasemia gene
- Any other congenital or hereditable conditions.
27. Are you possibly (distantly) related to the father of the baby?*
- Yes
- No
- I don't know
The father of the baby is my:

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
This field is for validation purposes and should be left unchanged.

Please first register at our practice before filling out the questionnaire

Consent form

We ask everybody who comes to our practice to fill out a consent form. You can already read the form here.

Consent Form

Since May 1th 2014 we ask everybody who comes to our practice to fill out a consent form. Below you can check the form. Please notice that this is just an example of the form. You'll receive the consent form at your intake, and you need to sign this. The form here on our website is just so you can prepare yourself.

Since May 1th 2014 we ask everybody who comes to our practice to fill out a consent form. Below you can check the form. Please notice that this is just an example of the form. You'll receive the consent form at your intake, and you need to sign this. The form here on our website is just so you can prepare yourself.
Consultation with other health care providers
To provide the best care, sometimes we need to have consultation with other health care providers, such as your general practitioner, the consultation bureau (OKC) en sometimes the gynaecologist. We ask your permission.
- Yes
- No
Sonograms
In our practice, we make a term ultrasound for everybody around 10 weeks pregnancy to determine your due date.

We also educate you about the possiblity to do a combination test and/or a 20 week scan. To advance the quality of health care, we are obliged to register the results of these examinations in a nationwide database, which is named PERIDOS. The registration takes place with your BSN. Of course we will handle these data carefully.

Between 18 and 22 weeks pregnancy we can check with an ultrasound if there are abnormalities. Not all the abnormalities can be seen on the 20 week scan, so there is no guarantee for a healthy baby. The 20 week scan is not required. For more information you can check: www.prenatalescreening.nl
- Yes
- No
Trainees
In our practice we frequently work with obstetricians in training of the Verloskunde Academie Amsterdam (VAA). Depending on the year of their course (1 to 4), they’ll do consulting hours, deliveries and maternity visits. Always with our supervision. If you object against the presence of a trainee, you can always point this out to the obstetrician.

Do you agree to the treatment by a trainee?
- Yes
- No
Comments
This field is for validation purposes and should be left unchanged.