We would like to ask you to completely fill out this form before your second appointment at the practice. We will check all the data en put it in your file. Together we will talk about all this when you come to the practice for your intake appointment. When you filled out this form we will have more time during the intake to talk about everything and to answer all your questions.

We ask a lot of things about your health and lifestyle, family history and obstetrical history. This is important information for us to give you the best, most optimal and safe care during your pregnancy and labour.


Health and lifestyle:

Do you smoke?

Do you want to quit smoking?

Do you drink alcohol (in pregnancy)?

Do you use drugs?

Have you ever had a blood transfusion?

Have you ever had thrombosis?

Do you ever suffer from bladder infection?

Do you ever have a cold sore (herpes virus)?

Does your partner ever have a cold sore?

Have you ever had a sexually transmitted disease (STD)?

Have you ever had the chicken pox?

Are you already using a pregnancy multivitamin?

Are you already using folic acid?


Obstetrical history:

Have you been pregnant before?
YesNo this is my first pregnancy

If no: You have finished the questionnaire, you can skip below. Click submit at the bottom of the list.

Have you ever had a miscarriage?

Have you ever had an abortion?

- Name
- Date of birth
- Sex
- Birth weight
- Who / what practice or hospital was your caregiver at that time?
- Was there any special circumstance during pregnancy?
- At how many weeks and days did you give birth?
- How did the labour start? (Contractions, water broke, you got induced?)?
- How long did it last from the beginning of the regular contractions until you were 10cm dilated and started pushing?
- How long did you have to push?
- Was there any special circumstance or problem during labour and pushing?
- Did the placenta and membranes come out spontaneously and without problems?
- How much blood loss did you have during childbirth? Were there any problems?
- Did you need stitches? (rupture or episiotomy?)
- Did any other problems or special circumstances occur?
- Did you have any problems during the first week after birth and did you breast- or bottle feed?
(you can increase the text box by clicking the bottom right corner of the white plane and dragging this corner)