See You Soon in Our Practice!

Questionnaire for new clients of De Kern

Welcome to De Kern midwifery practice! We would like to ask you to fill out this questionnaire and bring it with you to your first appointment with one of the midwives.Would you please bring your ID-card and insurance card as well?

See you soon in our practice!

Name:Date of birth:

How did you find out about our practice?

О I’ve been to De Kern before Trough:О the internet/website О my doctor/GP О family or friends

Current Pregnancy

Did you use contraceptive pills or an IUD in the year prior to this pregnancy? / О Yes
Use ended per: / О No
What was the date of the first day of your latest period?
Did you menstruate regularly? / О Yes, every …….. days / О No
What was the date of your first positive pregnancy test?
Are you taking folic acid supplements? (in order to prevent spina bifida we recommend a dose of 0,4 to 0,5 mg folic acid (vitamin B11) until the 11th week of your pregnancy) / О Yes, since before I conceived
О Yes, since I found out I was pregnant / О No

For your information: we will provide a declaration of pregnancy at your second pregnancy check-up

General medical history

Do you have any medical conditions? / О Yes, namely: / О No
Are you in treatment by a specialist or were you in the past? / О Yes, in the year:
Type of specialist: / О No
Have you ever been admitted to a hospital? / О Yes, in the year:
Immediate cause: / О No
Have you ever had an operation? / О Yes, in the year:
Immediate cause: / О No
Have you ever had a bloodtransfusion? / О Yes / О No
Have you ever suffered from thrombosis? / О Yes / О No
Have you ever suffered from a UTI or bladder infection? / О Yes, a few times
О Yes, many times / О No
Have you ever been diagnosed with a vaginal yeast infection(candida)? / О Yes, a few times
О Yes, many times / О No
Have you ever had gingivitis (inflamed gums)? / О Yes / О No
Have you or your partners ever had a cold sore (herpes virus)? / О Yes, I have
О Yes, my partner has / О No
Have you ever suffered from chicken pox? / О Yes
О I’m not sure / О No
Have you been vaccinated for rubella? / О Yes
О I’m not sure / О No
Have you ever been diagnosed with anemia? / О Yes / О No
Have you been in a hospital in another country in the past six months? / О Yes, country: / О No
Are you currently taking any medication? / О Yes, name:
Dose: / О No
Did you take any medication in the six months prior to this pregnancy? / О Yes, name:
Dose: / О No

Medical history related to pregnancy and gynecology

Have you been pregnant before? / О Yes, number of deliveries:
number of miscarriages:
number of abortions: / О No
If so, have you experienced any of the following?
(please check the relevant boxes) / О pelvic pain,О anemia,О high blood pressure, О pregnancy related diabetes, О premature delivery, О induced labour, О vacuum extraction,О caesarean section,Оpost partum bleeding,
О big baby,О baby was too small,О jaundiced baby (yellow skin), О mastitis (breast inflammation),О difficulty recovering physically after delivery,О difficulty recovering mentally after delivery,
О Other issues: / О None
Have you ever had a pap smear (cervical test)? / О Yes, year:
О I didn’t require any follow up testing
О I had follow up tests / О No
Have you or your partner ever been diagnosed with an STI (sexually transmitted infection)? / О Yes, namely:
Year: / О No
Were you exposed to di-ethylstilbestrol when your mother was pregnant? (if you were born before 1977) / О Yes
О I’m not sure / О No
Are you circumcised? / О Yes / О No

Mental Health history

Have you ever received treatment from a psychologist or psychiatrist? / О Yes, year:
Immediate cause: / О No
Have you ever suffered from burn out, (postpartum) depression, an anxiety disorder or an eating disorder? / О Yes, namely:
Year: / О No
On a scale of 1 to 10, how would you rate your current mental health?
Have you ever been the victim of domestic violence or child abuse? / О Yes / О No
Have you been involved with child protective services during your own childhood? / О Yes / О No
Have you had any bad sexual experiences so traumatic they might influence your pregnancy or delivery? / О Yes / О No

Allergies

Are you allergic to any medication? (for example antibiotics, pain killers or anaesthetics) / О Yes, name:
Allergic reaction: / О No
Do you have any other allergies? (for example latex, certain metals, bandages) / О Yes, name:
Allergic reaction: / О No

Smoking, alcohol and drugs

Did you smoke prior to this pregnancy? / О Yes, ……. cigarettes a day / О No
Do you currently smoke? / О Yes, ……. cigarettes a day / О No
Does your partner smoke? / О Yes, ……. cigarettes a day / О No
Did you drink alcohol prior to this pregnancy? / О Yes, ……..glasses per week / О No
Do you currently drink alcohol? / О Yes, …….. glasses per week / О No
Have you ever used drugs? / О Yes, drug:
Last use in (year): / О No
Do you currently use drugs? / О Yes, drug: / О No
Does your partner use drugs? / О Yes, drug: / О No

Family history

Does anyone in your immediate family have diabetes (type 1 or 2)? / О Yes, my: / О No
Does anyone in your immediate family have high blood pressure? / О Yes, my: / О No
Does anyone in your immediate family have thyroid problems? / О Yes, my: / О No
Does anyone in your immediate family have a blood clotting disorder? / О Yes, my: / О No
Are there birth defects or hereditary disorders in your or you partner’s family, that you know of? / О Yes, namely (which disorder and what relation to you): / О No

(Also consider still born babies or children who died young, family members who had repeated miscarriages, family members who have Huntington’s disease, hereditary anemia, Down syndrome ore other chromosome disorders or children or adults with a mental disability)

Have you read the information on our website on antenatal screening? / О Yes / О No

Food

Are you aware of the food restrictions during pregnancy? / О Yes / О No
Do you follow a specific diet? / О Yes, namely: / О No
What was your weight before your pregnancy? / ………kg

Thank you for filling out this questionnaire! Would you please bring your ID and insurance card to your first appointment?

The questions you have for the midwife: