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Guidance during pregnancy, childbirth and puerperium
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* Indicates required question
First name
*
Your answer
Maiden name
*
Your answer
Date of birth
(mm-dd-yy)
*
MM
/
DD
/
YYYY
What is your country of birth/origin?
*
Your answer
Street + house number
*
Your answer
Postal code and Residence
*
Your answer
Country
*
Your answer
BSN-number
*
Your answer
Telephone number (mobile + home)
*
Your answer
Email address
*
Your answer
Marital status
*
Married
Cohabiting
Single
Long Distance Relationship
Telephone number of partner/contact person
*
Your answer
Insurer
*
Your answer
Insurance policy number
*
Your answer
General practitioner
*
Your answer
The first day of the last menstrual period is
*
MM
/
DD
/
YYYY
How long is your menstrual cycle usually?
*
Your answer
How many pregnancies have you had before?
*
Your answer
Date of first positive pregnancy test
*
MM
/
DD
/
YYYY
How did you find our practice?
*
Previous pregnancy
Family
General practitioner
Internet
Other
Notes
Your answer
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