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
О Yes
О No
the year prior to this pregnancy?
Use ended per:
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
О Yes, since before I conceived
О No
order to prevent spina bifida we recommend a О Yes, since I found out I was pregnant
dose of 0,4 to 0,5 mg folic acid (vitamin B11)
until the 11th week of your pregnancy)
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?
Have you ever been admitted to a hospital?
О Yes, in the year:
Type of specialist:
О Yes, in the year:
Immediate cause:
О Yes, in the year:
Immediate cause:
О Yes
О Yes
О Yes, a few times
О Yes, many times
О Yes, a few times
О Yes, many times
О Yes
О Yes, I have
О Yes, my partner has
О Yes
О No
Have you ever had an operation?
Have you ever had a blood transfusion?
Have you ever suffered from thrombosis?
Have you ever suffered from a UTI or bladder
infection?
Have you ever been diagnosed with a vaginal
yeast infection (candida)?
Have you ever had gingivitis (inflamed gums)?
Have you or your partners ever had a cold
sore (herpes virus)?
Have you ever suffered from chicken pox?
О No
О No
О No
О No
О No
О No
О No
О No
О No
Have you been vaccinated for rubella?
Have you ever been diagnosed with anemia?
Have you been in a hospital in another
country in the past six months?
Are you currently taking any medication?
Did you take any medication in the six months
prior to this pregnancy?
О I’m not sure
О Yes
О I’m not sure
О Yes
О Yes, country:
О Yes, name:
Dose:
О Yes, name:
Dose:
О No
О No
О No
О No
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 pelvic pain, О anemia, О high blood pressure,
О pregnancy related diabetes, О premature
delivery, О induced labour, О vacuum extraction,
О caesarean section, О post 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 No
О Yes, year:
О I didn’t require any follow up testing
О I had follow up tests
О Yes, namely:
Year:
О Yes
О I’m not sure
О No
О Yes
О No
Have you ever received treatment from a
psychologist or psychiatrist?
О Yes, year:
О No
Have you ever suffered from burn out,
(postpartum) depression, an anxiety disorder
or an eating disorder?
О Yes, namely:
If so, have you experienced any of the
following?
(please check the relevant boxes)
Have you ever had a pap smear (cervical test)?
Have you or your partner ever been diagnosed
with an STI (sexually transmitted infection)?
Were you exposed to di-ethylstilbestrol when
your mother was pregnant? (if you were born
before 1977)
Are you circumcised?
О None
О No
О No
Mental Health history
Immediate cause:
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
О Yes, name:
Allergic reaction:
О No
О Yes, name:
Allergic reaction:
О No
Allergies
Are you allergic to any medication? (for
example antibiotics, pain killers or
anaesthetics)
Do you have any other allergies? (for example
latex, certain metals, bandages)
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:
О No
Last use in (year):
Do you currently use drugs?
О Yes, drug:
О No
Does your partner use drugs?
О Yes, drug:
О No
О Yes, my:
О No
Family history
Does anyone in your immediate family
have diabetes (type 1 or 2)?
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
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
Food
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:
-