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

If you are human, leave this field blank.

Link ontvangen formulier?

Did you receive a link from us to fill out this form?

Nee

Datum afspraak? *

If so, on what date do you have an appointment with us?

Tijd afspraak? *

At what time do you have an appointment with us?

Naam *

E-mail

Geboortedatum *

Geboorteland *

Leeftijd *

Lengte *

Gewicht *

Je bent...

You are

married or registered partner

unmarried with partner

single

Naam huisarts/huisartspraktijk? *

What is the name of your general practitioner or the general practice?

Eerste gesprek huisarts / specialist / andere arts? *

Did you have a first talk with your general practitioner, specialist or other doctor in connection with the request for an abortion?

Yes

Datum eerste gesprek huisarts, specialist of andere arts *

Date of first talk with your general practitioner, specialist or other doctor in connection with the request for an abortion

Eerste dag van de laatste menstruatie bekend? *

Do you know when the first day of your last period was?

Yes

Eerste dag van laatste menstruatie? *

When was the first day of your last period?

Regelmatig ongesteld? *

Do you have regular periods?

Yes

Hoeveel dagen bloedverlies? *

How many days do you lose blood then?

Pijn tijdens ongesteldheid? *

Do you have pain during your period?

Yes

Houdt u bedrust? *

Do you stay in bed during your period?

Yes

Gebruikt u pijnstillers? *

Do you use painkillers during your period?

Yes

Eerder zwanger geweest? *

Have you been pregnant before?

Yes

Hoeveel kinderen heeft u? *

How many children do you have?

Problemen bij zwangerschap(pen) / bevalling(en)? *

Have there been any problems with this/these pregnancy/pregnancies and delivery/deliveries?

Yes

Toelichting

Do you want to elaborate?

Borstvoeding? *

Are you currently breastfeeding?

Yes

Miskraam? *

Have you had a miscarriage?

Yes

Eerder abortus gehad? *

Have you had an abortion before?

Yes

Abortus in jaar en waar? *

Bij gynaecoloog onder behandeling? *

Have you been treated by a gynaecologist?

Yes

Waarvoor? *

For what condition?

Behandeld voor geslachtsziekte? *

Have you been treated for a venereal disease?

Yes

Eileiderontsteking gehad? *

Have you had a fallopian tube inflammation?

Yes

Operatie ondergaan? *

Have you undergone surgery?

Yes

Waarom en wanneer? *

Why and when?

Narcose gehad? *

Did you then have anaesthesia?

Yes

Plaatselijke verdoving gehad? *

Have you had local anaesthesia (e.g. at the dentist)?

Yes

Allergisch verdoving? *

If yes: where you allergic (hypersensitive) to the sedative?

Yes

Allergische reacties *

If yes: what was the allergic (hypersensitive) reaction?

Onder behandeling geweest i.v.m. hart? *

Have you ever been treated for a heart condition?

Yes

Welk jaar en waarom? *

If yes: In what year was the last treatment and why?

Allergisch/overgevoelig voor *

Are you allergic (hypersensitive) to:

Iodine

Plaster

Metal (nickel/chrome)

Rubber / latex / kiwis / figs

Soy

Medicines

Does not apply

Welke geneesmiddelen? *

Which medicines?

Overige allergieën? *

Do you have any other or additional allergies?

Yes

Welke allergieën? *

If yes, what allergies?

Allergische reacties *

What allergic reaction do you get?

Red spots

Itch

Other

Eerste hulp ivm allergie? *

Have you ever been admitted to the emergency room due to severe allergies?

Yes

Welk jaar en waarom? *

If yes: In what year and why?

Geneesmiddelen/medicijnen laatste 24 uur? *

Have you taken any medicines/medication in the last 24 hours, including puffs or St. John's wort?

Yes

Welke medicijnen? *

Which medicines?

Drugs laatste 24 uur? *

Have you used drugs in the last 24 hours?

Yes

Welke drugs? *

Which drugs?

Rookt u? *

Do you smoke?

Yes

Aantal per dag? *

Drink je? *

Do you drink alcohol?

Yes

Aantal glazen per week? *

Slachtoffer huiselijk geweld?

Have you been a victim of domestic violence?

Yes, physical

Yes, sexual

Yes, emotional

Slachtoffer negatieve seksuele ervaringen? *

Have you been the victim of negative sexual experiences outside the domestic circle?

Yes

Ziektes *

Do you have any of the following diseases? Or have you had any in the past?

High blood pressure

Thrombosis (in the past)

Anaemia (in the last six months)

Bladder infection (in the last six months)

Fainting/hyperventilation

Migraine with aura

Sickle cell anaemia / thalassaemia

Does not apply

Wanneer voor het laatst klachten? *

In which year did you last have complaints?

Onder behandeling arts? *

Are you being treated by a doctor for this?

Yes

Bloedstollingstoornissen? *

Do you suffer from blood coagulation disorders?

Yes

Wanneer voor het laatst klachten? *

In which year did you last have complaints?

Onder behandeling arts? *

Are you being treated by a doctor for this?

Yes

Nierziekte? *

Do you suffer from kidney disease?

Yes

Wanneer voor het laatst klachten? *

In which year did you last have complaints?

Onder behandeling arts? *

Are you being treated by a doctor for this?

Yes

Ziekten van de schildklier? *

Do you suffer from thyroid problems?

Yes

Wanneer voor het laatst klachten? *

In which year did you last have complaints?

Onder behandeling arts? *

Are you being treated by a doctor for this?

Yes

Diabetes? *

Do you suffer from diabetes?

Yes

Wanneer voor het laatst klachten? *

In which year did you last have complaints?

Onder behandeling arts? *

Are you being treated by a doctor for this?

Yes

Leverziekte? *

Do you suffer from liver disease (hepatitis / jaundice)?

Yes

Wanneer voor het laatst klachten? *

In which year did you last have complaints?

Onder behandeling arts? *

Are you being treated by a doctor for this?

Yes

Astma of chronische bronchitis? *

Do you suffer from asthma or chronic bronchitis?

Yes

Wanneer voor het laatst klachten? *

In which year did you last have complaints?

Onder behandeling arts? *

Are you being treated by a doctor for this?

Yes

Psychische/psychiatrische aandoening? *

Do you suffer from a mental or psychiatric disorder?

Yes

Wanneer voor het laatst klachten? *

In which year did you last have complaints?

Onder behandeling arts? *

Are you being treated by a doctor for this?

Yes

Epilepsie (vallende ziekte)? *

Do you suffer from epilepsy?

Yes

Wanneer voor het laatst klachten? *

In which year did you last have complaints?

Onder behandeling arts? *

Are you being treated by a doctor for this?

Yes