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Birth in Holland

Birth in Holland

Building confidence for a better start for your family

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Medical history

Intake questionnaire

Personal details

Name(Required)
Initials(Required)
Maiden name (if applicable)
Date of Birth(Required)
Address(Required)

Employment

Do you have a job where you have to stand for long periods of time?
Do you work unsocial hours or night shifts?
Are you at risk of exposure to radiaoctive substances or ionising radiation?

Health

Are you taking Folic Acid?
Are you taking pregnancy vitamins?
Do you smoke?
Do you drink alcohol?
1 glass of wine = 3 units. 1 beer = 1 unit.
1 beer = 1 unit. 1 glass of wine = 3 units
Do you use drugs?
Do you take any medication?
Do you eat fresh fruit and vegetables every day?
Do you follow a special diet?

Are you in good health?
Have you been vaccinated against Rubella?
(German measles)
Have you had Chicken Pox or been vaccinated against Chicken Pox?
(Varicella)
Have you had Corona or been vaccinated against Corona?
(Covid-19)
(Vaccination)
(Infection)
Have you ever had a blood transfusion?
Have you been treated in or admitted to a hospital in a foreign country within the last two months?

Are you suffering from or have you ever suffered from any of the following medical conditions?

Cystitis
Urine infection
If yes, how often?
Candida
Vaginal yeast infection
If yes, how often?
Infection in gums
Gingivitis
Allergies
Cold sores
Diabetes
Thrombosis
Do you bruise easily or do wounds take a long time to stop bleeding?
Cardio-vascular disease
Heart and circulatory problems
Liver or kidney disease
Epilepsy
Cancer
Asthma/chronic bronchitis (COPD)
Rheumatism
Eating disorders
Are you being (or have been) treated by a medical specialist?
Hospital consultant
Month-Year
Have you every had any surgery?
Are you a blood relation of the father of the baby?
Blood relation
Do you have any hereditary disease(s)?

Psycho-social care

Have you ever had contact with:
Have you ever used psychiatric medication?
Do you have enough support around you?
Have you ever been abused?
Have you ever been a witness of abuse?
Have you ever been a victim of sexual abuse?
Have you had a negative experience with a health care worker/carer?

Family history

Is your partner in good health?
Does your partner smoke?
If yes, does your partner smoke in the house?
Does your partner ever suffer from cold sores?
Does your partner have a hereditary disease?

Does anyone in your family or in your partner's family suffer from any of the following diseases:

High blood pressure
Diabetes
Hereditary anaemia
Thalassemia/Sickle-cell disease
Clotting disorder/haemophilia
Congenital blindness or poor vision
Congenital deafness
Heart defects
Diseases of the central nervous system
Hip defects
Muscular diseases
Cleft lip or cleft palate?
Schisis
Spina bifida, anencephaly or hydrocephaly?
Down's Syndrome
Mental retardation (eg. Fragile X syndrome)
Any other hereditary or congenital defects?

Finances

Do you and/or your partner combined earn less than €1000 per month?
Are you experiencing financial difficulties?
If yes, do you have help to deal with these difficulties?

Obstetric and gynaecological history

Do you have children?

If no, scroll to the next section

DD dash MM dash YYYY
1st child
Weeks...days...(eg. 40 weeks, 3 days)
Sex
Name
1st child
1st child (grams)
1st child
1st child
DD dash MM dash YYYY
2nd child
2nd child
Weeks...days...(eg. 40 weeks, 3 days)
Sex
2nd child
Name
2nd child
2nd child (grams)
2nd child
2nd child
DD dash MM dash YYYY
3rd child
Weeks...days...(eg. 40 weeks, 3 days)
Sex
Name
3rd child
3rd child (grams)
3rd child
3rd child
DD dash MM dash YYYY
4th child
Weeks...days...(eg. 40 weeks, 3 days)
Sex
Name
4th child
4th child (grams)
4th child
4th child
Do you have a child with a congenital defect?
Do you have one (or more) child(ren) under the care of a paediatrician?
Do you have any children who don't live with you?
Have you experienced problems with any of your children with regard to health, child support services or parenting?

Have you ever had a miscarriage?
Have you ever had an ectopic pregnancy?
Have you ever been diagnosed with an abnormality of your cervix or uterus?
Have you ever had a cervical smear test?
Have you ever had a sexually transmitted disease?
Have you been circumcised?

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Birth in Holland
Gerbrandylaan 36
2625LR Delft

info@birthinholland.com

KVK: 67260896
AGB code: 0800/3339
BTW: 856900990B01

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Birth in Holland

Providing courses, pregnancy & birth services for international families.

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