Your midwife in the Heemstede region

Practice
Het Ooievaarsnest

documents

All relevant information conveniently and securely under one roof

To give you the best possible service, we ask for some information from you before you visit us. You can either fill this in digitally below, or fill in the form via Word and mail it to us.

Our practice is part of Rondom Zwanger. Here you can find all kinds of practical information and education on pregnancy, maternity care and health. View the leaflets and interactive video on the website:

For your first appointment

To best adapt our care to your situation, it is important that we are well informed about your (medical) background. Below you will find questions relating to your medical and social background. If you complete this form for your first appointment, the midwife will discuss this with you.

Fill in digitally?

Download form:

Pregnant data

Nickname

Initials

Girl's surname

Date of birth

Nationality

Dutch-speaking

otherwise

Street & house number.

Postcode

Place of residence

Landline telephone number.

Mobile phone number.

Marital status

otherwise

Occupation

Full-time/part-time

Religious beliefs (optional)

Name of general practitioner

Name of Health Insurer

Policy number

National Insurance Number

How did you find us?

Partner details

Nickname

Initials

Surname

Date of birth

Mobile phone number.

Occupation

Full-time/part-time

Is this your first pregnancy?

Is this your first pregnancy

If no; enter the number below:

Number of births

Number of miscarriages

Number of abortions

Number of children

If possible, bring details of your previous pregnancy(ies) and delivery(ies) with you to the first check-up.

Is this a planned pregnancy

How long did it take you to get pregnant (in months)

Menstrual cycle

Do you remember the first day of your last period

If yes: enter the date below

Did this period proceed normally

If no, why was menstruation different

Did you have a regular cycle

If yes, how many days did your cycle count mostall

Have you used contraception before?

If yes, which

When did you stop doing this

When did your pregnancy test first give a positive result

Have you had a termly ultrasound yet

If you have already had a term ultrasound elsewhere, bring the results with you to your first check-up.

Medical data

What is your height (in cm)

How much did you weigh before getting pregnant (in kg)

Have you ever had a bladder infection

If yes, how many times have you had

When

Have you ever had very inflamed gums

Have you ever had a vaginal yeast infection

If yes, how many times have you had

When

Have you ever had a cervical smear

If yes, when (date)

Which PAP was it

If the PAP was abnormal, what treatment did you have

Have you ever had chickenpox yourself

Have you or your partner ever had a cold sore

We will give you additional information about this during the first check-up.

Have you been admitted to a foreign hospital in the last six months

Have you ever had a blood transfusion

If yes, when

How have you been treated

Take your folic acid

If yes, when did you start this

If no: It is recommended to take extra folic acid (1 x daily 0.5 mg folic acid) until the 11th week of pregnancy. These tablets are available through pharmacies and drugstores.

Have you been taking any medication just before or during this pregnancy

If yes, which

In what quantities

Do you currently have a condition monitored by your GP

If yes, which condition

Have you ever had surgery

If yes, what did you have surgery on

When

Have you had negative experiences of sexual violence (such as sexual assault, rape, incest) or domestic violence

If yes: During the first check-up, we will discuss with you to what extent this will affect your experience of pregnancy and childbirth.

Have you ever been under treatment with a psychologist or psychiatrist

If yes, what was the reason

When

Have you ever received treatment from a specialist in connection with a condition

If yes, which condition

When

Have you ever experienced a venereal disease (STD)

If yes, which STD

When

How have you been treated

Are you allergic to certain things or medicines

If yes, what for

Do you smoke, or does your partner smoke

If yes, how much do you smoke per day

If stopped, when

Did you use alcohol before pregnancy or are you currently using it

If yes, how much alcohol do you consume(d)

Have you ever used or are currently using drugs

If yes, what drug(s) do you use

How often

When last

Do you follow a particular diet (e.g. vegetarian)

If yes, what kind of diet

Do you consider yourself to have a healthy diet

If no, why not

Disk of five, see also www.voedingcentrum.nl

Have you ever been counselled by Bureau of Youth Health

If yes, what for

When

Have you ever been in debt restructuring or dealt with other assistance agencies

If yes, what for

When

Are there any (health) problems not yet mentioned above

If yes, which

Family background

Are your (any) previous children healthy

If no, what condition(s) do they have

Is your partner (the father of your baby) healthy

If no, why not

Does your partner have children from a previous relationship

If yes, are these children healthy

Are there any congenital defects in your family or your partner's family (e.g. Down syndrome, spina bifida, hazelip, heart defects, etc.)?

If yes, which condition

At whom

Do you know if this abnormality is hereditary

Did any of your grandmothers or mothers have multiple stillborn babies, at a gestational age of more than 4 months

If yes, is this a known cause

Are there any members in your family with psychological problems (e.g. depression, psychosis, psychological disorders)

If yes, who

What kind of treatment

Are there any members in your/your family who have asthma, hay fever or eczema

If yes, who

Does diabetes occur in your immediate family

If yes, who

Does high blood pressure occur in your immediate family

If yes, who

Does tuberculosis occur in your close family

If yes, who

Does your close family have thyroid problems

If yes, who

Other

Are there any other issues not covered above that you think are important for us to know about

We are here to answer your questions

Main location
Raadhuisstraat 24
2101 HG Heemstede

info@verloskundigenhetooievaarsnest.nl

For consultation hours, you can also visit our locations in Zandvoort and Haarlem.

Phone
We can be reached by phone at:

Emergency
For emergencies and deliveries, please call: 023-2100153

You may also submit non-urgent enquiries via email. We will respond as soon as possible.

Practice
Het Ooievaarsnest

All relevant information conveniently and securely under one roof

For your first appointment

We are here to answer your questions

9,8

4.6

KNOV

Sign up without obligation

Practice Het Ooievaarsnest

All relevant information conveniently and securely under one roof

For your first appointment

We are here to answer your questions

9,8

4.6

KNOV

Sign up without obligation

Practice
Het Ooievaarsnest