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Anamnesis form

Fill in the online anamnesis form below.

Stimezo Zwolle will handle your data with care. If you prefer to download the form, that is also possible.

Click here to download the Word file, fill it in and send it to vragen@stimezo-zwolle.nl

You are
Did you have a first talk with your general practitioner, specialist or other doctor in connection with the request for an abortion?
Date of first talk with your general practitioner, specialist or other doctor in connection with the request for an abortion
Do you know when the first day of your last period was?
When was the first day of your last period?
Do you have regular periods?
How many days do you lose blood then?
Do you have pain during your period?
Do you stay in bed during your period?
Do you use painkillers during your period?
Have you been pregnant before?
How many children do you have?
Have there been any problems with this/these pregnancy/pregnancies and delivery/deliveries?
Do you want to elaborate?
Are you currently breastfeeding?
Have you had a miscarriage?
Have you had an abortion before?
Have you been treated by a gynaecologist?
For what condition?
Have you been treated for a venereal disease?
Have you had a fallopian tube inflammation?
Have you undergone surgery?
Why and when?
Did you then have anaesthesia?
Have you had local anaesthesia (e.g. at the dentist)?
If yes: where you allergic (hypersensitive) to the sedative?
If yes: what was the allergic (hypersensitive) reaction?
Have you ever been treated for a heart condition?
If yes: In what year was the last treatment and why?
Are you allergic (hypersensitive) to:
Which medicines?
Do you have any other or additional allergies?
If yes, what allergies?
What allergic reaction do you get?
Have you ever been admitted to the emergency room due to severe allergies?
If yes: In what year and why?
Have you taken any medicines/medication in the last 24 hours, including puffs or St. John's wort?
Which medicines?
Have you used drugs in the last 24 hours?
Which drugs?
Do you smoke?
Have you been a victim of domestic violence?
Have you been the victim of negative sexual experiences outside the domestic circle?
Do you have any of the following diseases? Or have you had any in the past?
In which year did you last have complaints?
Are you being treated by a doctor for this?
Do you suffer from blood coagulation disorders?
In which year did you last have complaints?
Are you being treated by a doctor for this?
Do you suffer from kidney disease?
In which year did you last have complaints?
Are you being treated by a doctor for this?
Do you suffer from thyroid problems?
In which year did you last have complaints?
Are you being treated by a doctor for this?
Do you suffer from diabetes?
In which year did you last have complaints?
Are you being treated by a doctor for this?
Do you suffer from liver disease (hepatitis / jaundice)?
In which year did you last have complaints?
Are you being treated by a doctor for this?
Do you suffer from asthma or chronic bronchitis?
In which year did you last have complaints?
Are you being treated by a doctor for this?
Do you suffer from a mental or psychiatric disorder?
In which year did you last have complaints?
Are you being treated by a doctor for this?
Do you suffer from epilepsy?
In which year did you last have complaints?
Are you being treated by a doctor for this?