{"id":2912,"date":"2021-06-28T11:47:32","date_gmt":"2021-06-28T11:47:32","guid":{"rendered":"https:\/\/stimezo.naareva.nl\/keuzehulpformulier\/"},"modified":"2026-10-01T10:20:44","modified_gmt":"2026-10-01T10:20:44","slug":"decision-aid-form","status":"publish","type":"page","link":"https:\/\/www.stimezo-zwolle.nl\/en\/decision-aid-form\/","title":{"rendered":"Decision aid form"},"content":{"rendered":"<!--themify_builder_content-->\n<div id=\"themify_builder_content-2912\" data-postid=\"2912\" class=\"themify_builder_content themify_builder_content-2912 themify_builder tf_clear\">\n                    <div  data-css_id=\"bdtr746\" data-lazy=\"1\" class=\"module_row themify_builder_row fullheight fullwidth_row_container tb_bdtr746 tb_first tf_w\">\n                        <div class=\"row_inner col_align_top tb_col_count_2 tf_box tf_rel\">\n                        <div  data-lazy=\"1\" class=\"module_column tb-column col4-2 tb_h19x749 first\">\n                    <!-- module text -->\n<div  class=\"module module-text tb_0mt2749   \" data-lazy=\"1\">\n        <div  class=\"tb_text_wrap\">\n        <h1><span lang=\"EN-GB\">Decision aid form<\/span><\/h1>    <\/div>\n<\/div>\n<!-- \/module text -->        <\/div>\n                    <div  data-lazy=\"1\" class=\"module_column tb-column col4-2 tb_galj749 last\">\n                            <\/div>\n                        <\/div>\n        <\/div>\n                        <div  data-css_id=\"4jf8746\" data-lazy=\"1\" class=\"module_row themify_builder_row fullwidth_row_container tb_4jf8746 tf_w\">\n                        <div class=\"row_inner col_align_top tb_col_count_1 tf_box tf_rel\">\n                        <div  data-lazy=\"1\" class=\"module_column tb-column col-full tb_8x04750 first\">\n                    <!-- module text -->\n<div  class=\"module module-text tb_vduu410   \" data-lazy=\"1\">\n        <div  class=\"tb_text_wrap\">\n        <h2>Use our decision aid and indicate your preferences<\/h2>\n<p>\u00a0<\/p>\n<p>In preparation for the consultation, please fill in the decision form below so that we can give you tailored advice.<\/p>\n<p>Top of form<\/p>    <\/div>\n<\/div>\n<!-- \/module text --><!-- module plain text -->\n<div  class=\"module module-plain-text tb_uuc1439 \" data-lazy=\"1\">\n        <div class=\"tb_text_wrap\">\n    <script>\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form 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d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gform-theme gform-theme--foundation gform-theme--framework gform-theme--orbital' data-form-theme='orbital' data-form-index='0' id='gform_wrapper_8' >\n                        <div class='gform_heading'>\n                            <p class='gform_description'><\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_8'  action='\/en\/wp-json\/wp\/v2\/pages\/2912' data-formid='8' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_8' class='gform_fields top_label form_sublabel_below description_above validation_below' data-column-layout='fill'><div id=\"field_8_18\" class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"><label id='gfield_label_8_18' class='gfield_label gform-field-label' for='input_8_18'><span class='gform-field-label__text'>Email<\/span><\/label><div class='gfield_description' id='gfield_description_8_18'>This field is for validation purposes and should be left unchanged.<\/div><div class='ginput_container'><input name='input_18' id='input_8_18' type='text' value='' autocomplete='new-password'\/><\/div><\/div><div id=\"field_8_1\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_above hidden_label field_validation_below gfield_visibility_visible\" data-group-id=\"f3bc783b\" data-field-span=\"6\"><label id='gfield_label_8_1' class='gfield_label gform-field-label' for='input_8_1'><span class='gform-field-label__text'>Naam<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_1' id='input_8_1' type='text' value='' class='large'    placeholder='Name*' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_8_3\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_above hidden_label field_validation_below gfield_visibility_visible\" data-group-id=\"f3bc783b\" data-field-span=\"6\"><label id='gfield_label_8_3' class='gfield_label gform-field-label' for='input_8_3'><span class='gform-field-label__text'>E-mail<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_3' id='input_8_3' type='email' value='' class='large'   placeholder='Email*' aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><fieldset id=\"field_8_6\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above hidden_label field_validation_below gfield_visibility_visible gfield--choice-align-vertical\" data-group-id=\"2c6e24ee\" data-field-span=\"12\"><legend id='gfield_label_8_6' class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Hoe vaak anticonceptie?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_8_6'>How often do you want to think about contraception?<\/div><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_8_6'>\n\t\t\t<div class='gchoice gchoice_8_6_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_6' type='radio' value='Every day'  id='choice_8_6_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_8_6\" aria-labelledby=\"label_8_6_0 gfield_label_8_6\"   \/>\n\t\t\t\t\t<label for='choice_8_6_0' id='label_8_6_0' class='gform-field-label gform-field-label--type-inline'>Every day<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_8_6_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_6' type='radio' value='Once a week'  id='choice_8_6_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_8_6_1' id='label_8_6_1' class='gform-field-label gform-field-label--type-inline'>Once a week<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_8_6_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_6' type='radio' value='Every month'  id='choice_8_6_2' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_8_6_2' id='label_8_6_2' class='gform-field-label gform-field-label--type-inline'>Every month<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_8_6_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_6' type='radio' value='Every 3 months'  id='choice_8_6_3' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_8_6_3' id='label_8_6_3' class='gform-field-label gform-field-label--type-inline'>Every 3 months<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_8_6_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_6' type='radio' value='Every 3 years'  id='choice_8_6_4' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_8_6_4' id='label_8_6_4' class='gform-field-label gform-field-label--type-inline'>Every 3 years<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_8_6_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_6' type='radio' value='Every 5 years'  id='choice_8_6_5' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_8_6_5' id='label_8_6_5' class='gform-field-label gform-field-label--type-inline'>Every 5 years<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_8_12\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above hidden_label field_validation_below gfield_visibility_visible gfield--choice-align-vertical\" data-group-id=\"d9f18897\" data-field-span=\"12\"><legend id='gfield_label_8_12' class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Geen bezwaar hormonen?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_8_12'>Do you have no objection to using hormones?<\/div><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_8_12'>\n\t\t\t<div class='gchoice gchoice_8_12_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_12' type='radio' value='I have no objection to the use of hormones.'  id='choice_8_12_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_8_12\" aria-labelledby=\"label_8_12_0 gfield_label_8_12\"   \/>\n\t\t\t\t\t<label for='choice_8_12_0' id='label_8_12_0' class='gform-field-label gform-field-label--type-inline'>I have no objection to the use of hormones.<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_8_12_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_12' type='radio' value='I want to use contraception without hormones.'  id='choice_8_12_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_8_12_1' id='label_8_12_1' class='gform-field-label gform-field-label--type-inline'>I want to use contraception without hormones.<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_8_13\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above hidden_label field_validation_below gfield_visibility_visible gfield--choice-align-vertical\" data-group-id=\"409e8902\" data-field-span=\"12\"><legend id='gfield_label_8_13' class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Menstruatie wensen<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_8_13'>Do you have problems with your periods?<\/div><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_8_13'>\n\t\t\t<div class='gchoice gchoice_8_13_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='I want to be able to regulate or postpone my periods myself.'  id='choice_8_13_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_8_13\" aria-labelledby=\"label_8_13_0 gfield_label_8_13\"   \/>\n\t\t\t\t\t<label for='choice_8_13_0' id='label_8_13_0' class='gform-field-label gform-field-label--type-inline'>I want to be able to regulate or postpone my periods myself.<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_8_13_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='I want to have less pain and\/or blood loss during my period.'  id='choice_8_13_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_8_13_1' id='label_8_13_1' class='gform-field-label gform-field-label--type-inline'>I want to have less pain and\/or blood loss during my period.<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_8_13_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='I would like to have my periods every month.'  id='choice_8_13_2' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_8_13_2' id='label_8_13_2' class='gform-field-label gform-field-label--type-inline'>I would like to have my periods every month.<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_8_14\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above hidden_label field_validation_below gfield_visibility_visible gfield--choice-align-vertical\" data-group-id=\"5dbf8750\" data-field-span=\"12\"><legend id='gfield_label_8_14' class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Privacy belangrijk?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_8_14'>Is privacy important to you?<\/div><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_8_14'>\n\t\t\t<div class='gchoice gchoice_8_14_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_14' type='radio' value='Others may know that I use contraception.'  id='choice_8_14_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_8_14\" aria-labelledby=\"label_8_14_0 gfield_label_8_14\"   \/>\n\t\t\t\t\t<label for='choice_8_14_0' id='label_8_14_0' class='gform-field-label gform-field-label--type-inline'>Others may know that I use contraception.<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_8_14_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_14' type='radio' value='I do not want others to know that I use contraception.'  id='choice_8_14_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_8_14_1' id='label_8_14_1' class='gform-field-label gform-field-label--type-inline'>I do not want others to know that I use contraception.<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_8_15\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above hidden_label field_validation_below gfield_visibility_visible gfield--choice-align-vertical\" data-group-id=\"38d1796e\" data-field-span=\"12\"><legend id='gfield_label_8_15' class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Inbrengen door een arts?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_8_15'>Are you happy if a doctor inserts the contraceptive?<\/div><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_8_15'>\n\t\t\t<div class='gchoice gchoice_8_15_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_15' type='radio' value='I am happy for a doctor to insert the contraceptive.'  id='choice_8_15_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_8_15\" aria-labelledby=\"label_8_15_0 gfield_label_8_15\"   \/>\n\t\t\t\t\t<label for='choice_8_15_0' id='label_8_15_0' class='gform-field-label gform-field-label--type-inline'>I am happy for a doctor to insert the contraceptive.<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_8_15_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_15' type='radio' value='I do not want the doctor to insert the contraceptive.'  id='choice_8_15_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_8_15_1' id='label_8_15_1' class='gform-field-label gform-field-label--type-inline'>I do not want the doctor to insert the contraceptive.<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_8_17\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--has-description field_description_above hidden_label field_validation_below gfield_visibility_visible gfield--choice-align-vertical\" data-group-id=\"b0e911f8\" data-field-span=\"12\"><legend id='gfield_label_8_17' class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Vragen over je gezondheid<\/span><\/legend><div class='gfield_description' id='gfield_description_8_17'>Questions about your health (tick if applicable)<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_8_17'><div class='gchoice gchoice_8_17_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.1' type='checkbox'  value='None of the questions below apply'  id='choice_8_17_1'   aria-describedby=\"gfield_description_8_17\" aria-labelledby=\"label_8_17_1 gfield_label_8_17\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_8_17_1' id='label_8_17_1' class='gform-field-label gform-field-label--type-inline'>None of the questions below apply<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_8_17_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.2' type='checkbox'  value='Are you pregnant?'  id='choice_8_17_2'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_17_2' id='label_8_17_2' class='gform-field-label gform-field-label--type-inline'>Are you pregnant?<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_8_17_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.3' type='checkbox'  value='Are you 35 years or older and do you smoke?'  id='choice_8_17_3'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_17_3' id='label_8_17_3' class='gform-field-label gform-field-label--type-inline'>Are you 35 years or older and do you smoke?<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_8_17_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.4' type='checkbox'  value='Have you had a heart attack or stroke (CVA)?'  id='choice_8_17_4'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_17_4' id='label_8_17_4' class='gform-field-label gform-field-label--type-inline'>Have you had a heart attack or stroke (CVA)?<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_8_17_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.5' type='checkbox'  value='Do you have a congenital heart 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