Medical history Intake questionnaire Personal detailsName(Required) First Last Initials(Required) initials Maiden name (if applicable) Date of Birth(Required) Day Month Year Address(Required) Street Address Address Line 2 City County / State / Region ZIP / Postal Code Burgerservicenummer (BSN)(Required) EmploymentDo you have a job where you have to stand for long periods of time? 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 HealthAre 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 unitsDo you use drugs? No Yes If yes, what drugs do you use? If yes, how often BEFORE the pregnancy? If yes, how often 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? No Vegetarian Vegan Macrobiotic Other 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 had Corona or been vaccinated against Corona? Yes No (Covid-19) If yes, how many Covid vaccinations have you had? (Vaccination)If yes, when did you have Corona? (Infection)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 infectionIf yes, how often? Sporadic 1-2 x per year More than 2 x per year Candida No Yes Vaginal yeast infectionIf yes, how often? Sporadic 1-2 x per year More than 2 x per year Infection in gums No Yes GingivitisAllergies 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 problemsLiver 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 consultantIf yes, which specialist? If yes, which hospital? When? Month-YearWhat 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 a blood relation of the father of the baby? No Yes Blood relationIf yes, please explain how you are related: Do you have any hereditary disease(s)? No Yes If yes, please provide details:Psycho-social careHave 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 ever 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 historyIs 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 diseaseIf 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 SchisisIf 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:FinancesDo you and/or your partner combined earn less than €1000 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 historyDo you have children? No Yes If no, scroll to the next sectionDate of Birth DD dash MM dash YYYY 1st childWhere 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 childBirth weight 1st child (grams)Type of birth 1st child Further details/complications?1st child Date of Birth DD dash MM dash YYYY 2nd childWhere was he/she born? 2nd childHow far pregnant were you when you gave birth? Weeks...days...(eg. 40 weeks, 3 days)Sex Boy Girl 2nd childName First Middle Last 2nd childBirth weight 2nd child (grams)Type of birth 2nd child Further details/complications?2nd child Date of Birth DD dash MM dash YYYY 3rd childWhere 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 childBirth weight 3rd child (grams)Type of birth 3rd child Further details/complications?3rd child Date of Birth DD dash MM dash YYYY 4th childWhere 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 childBirth 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 Other 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: Δ
