{"id":2912,"date":"2021-06-28T11:47:32","date_gmt":"2021-06-28T11:47:32","guid":{"rendered":"https:\/\/stimezo.naareva.nl\/keuzehulpformulier\/"},"modified":"2021-11-04T16:40:45","modified_gmt":"2021-11-04T16:40:45","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 text -->\n<div  class=\"module module-text tb_rikj902   \" data-lazy=\"1\">\n        <div  class=\"tb_text_wrap\">\n        <form method=\"post\" enctype=\"multipart\/form-data\" id=\"vfbp-form-12\" class=\"vfbp-form\"><div style=\"display:none;\"><label for=\"vfbp-EMAIL-AN8fuQyoDLXem\">If you are human, leave this field blank.<\/label><input size=\"25\" autocomplete=\"off\" type=\"text\" name=\"vfbp-EMAIL-AN8fuQyoDLXem\" value=\"\" id=\"\"><\/div><input type=\"hidden\" name=\"_vfb-timestamp-12\" value=\"1777918790\" id=\"\"><input type=\"hidden\" name=\"_vfb-form-id\" value=\"12\" id=\"\"><div class=\"vfb-well vfb-col-12\" id=\"vfbField439\"><div class=\"vfb-form-group vfb-col-12\"><div><div class=\"\"><\/div><\/div><\/div><div class=\"vfb-col-12 vfb-fieldType-heading\" id=\"vfbField439\"><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-6 vfb-fieldType-text\" id=\"vfbField440\"><div class=\"vfb-form-group\"><label for=\"vfb-field-440\" class=\"vfb-control-label\">Naam <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><input id=\"vfb-field-440\" class=\"vfb-form-control\" placeholder=\"Name \" required=\"required\" type=\"text\" name=\"vfb-field-440\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-col-6 vfb-fieldType-email\" id=\"vfbField441\"><div class=\"vfb-form-group\"><label for=\"vfb-field-441\" class=\"vfb-control-label\">E-mail <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><input id=\"vfb-field-441\" class=\"vfb-form-control\" placeholder=\"E-mail\" required=\"required\" type=\"email\" name=\"vfb-field-441\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-radio\" id=\"vfbField442\"><label for=\"vfb-field-442\" class=\"vfb-control-label\">Hoe vaak anticonceptie? <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><span class=\"vfb-help-block\">How often do you want to think about contraception?<\/span><div class=\"vfb-radio\"><label><input id=\"vfb-field-442-0\" class=\"\" placeholder=\"\" required=\"required\" type=\"radio\" name=\"vfb-field-442\" value=\"Every day\">Every day<\/label><\/div><div class=\"vfb-radio\"><label><input id=\"vfb-field-442-1\" class=\"\" placeholder=\"\" required=\"required\" type=\"radio\" name=\"vfb-field-442\" value=\"Once a week\">Once a week<\/label><\/div><div class=\"vfb-radio\"><label><input id=\"vfb-field-442-2\" class=\"\" placeholder=\"\" required=\"required\" type=\"radio\" name=\"vfb-field-442\" value=\"Every month\">Every month<\/label><\/div><div class=\"vfb-radio\"><label><input id=\"vfb-field-442-3\" class=\"\" placeholder=\"\" required=\"required\" type=\"radio\" name=\"vfb-field-442\" value=\"Every 3 months\">Every 3 months<\/label><\/div><div class=\"vfb-radio\"><label><input id=\"vfb-field-442-4\" class=\"\" placeholder=\"\" required=\"required\" type=\"radio\" name=\"vfb-field-442\" value=\"Every 3 years\">Every 3 years<\/label><\/div><div class=\"vfb-radio\"><label><input id=\"vfb-field-442-5\" class=\"\" placeholder=\"\" required=\"required\" type=\"radio\" name=\"vfb-field-442\" value=\"Every 5 years\">Every 5 years<\/label><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-radio\" id=\"vfbField443\"><label for=\"vfb-field-443\" class=\"vfb-control-label\">Geen bezwaar hormonen? <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><span class=\"vfb-help-block\">Do you have no objection to using hormones?<\/span><div class=\"vfb-radio\"><label><input id=\"vfb-field-443-0\" class=\"\" placeholder=\"\" required=\"required\" type=\"radio\" name=\"vfb-field-443\" value=\"I have no objection to the use of hormones.\">I have no objection to the use of hormones.<\/label><\/div><div class=\"vfb-radio\"><label><input id=\"vfb-field-443-1\" class=\"\" placeholder=\"\" required=\"required\" type=\"radio\" name=\"vfb-field-443\" value=\"I want to use contraception without hormones.\">I want to use contraception without hormones.<\/label><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-radio\" id=\"vfbField444\"><label for=\"vfb-field-444\" class=\"vfb-control-label\">Last van menstruatie? <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><span class=\"vfb-help-block\">Do you have problems with your periods?<\/span><div class=\"vfb-radio\"><label><input id=\"vfb-field-444-0\" class=\"\" placeholder=\"\" required=\"required\" type=\"radio\" name=\"vfb-field-444\" value=\"I want to be able to regulate or postpone my periods myself.\">I want to be able to regulate or postpone my periods myself.<\/label><\/div><div class=\"vfb-radio\"><label><input id=\"vfb-field-444-1\" class=\"\" placeholder=\"\" required=\"required\" type=\"radio\" name=\"vfb-field-444\" value=\"I want to have less pain and\/or blood loss during my period.\">I want to have less pain and\/or blood loss during my period.<\/label><\/div><div class=\"vfb-radio\"><label><input id=\"vfb-field-444-2\" class=\"\" placeholder=\"\" required=\"required\" type=\"radio\" name=\"vfb-field-444\" value=\"I would like to have my periods every month.\">I would like to have my periods every month.<\/label><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-radio\" id=\"vfbField445\"><label for=\"vfb-field-445\" class=\"vfb-control-label\">Privacy belangrijk? <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><span class=\"vfb-help-block\">Is privacy important to you?<\/span><div class=\"vfb-radio\"><label><input id=\"vfb-field-445-0\" class=\"\" placeholder=\"\" required=\"required\" type=\"radio\" name=\"vfb-field-445\" value=\"Others may know that I use contraception.\">Others may know that I use contraception.<\/label><\/div><div class=\"vfb-radio\"><label><input id=\"vfb-field-445-1\" class=\"\" placeholder=\"\" required=\"required\" type=\"radio\" name=\"vfb-field-445\" value=\" I do not want others to know that I use contraception.\"> I do not want others to know that I use contraception.<\/label><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-radio\" id=\"vfbField446\"><label for=\"vfb-field-446\" class=\"vfb-control-label\">Inbrengen door een arts? <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><span class=\"vfb-help-block\">Insertion by a doctor?<\/span><div class=\"vfb-radio\"><label><input id=\"vfb-field-446-0\" class=\"\" placeholder=\"\" required=\"required\" type=\"radio\" name=\"vfb-field-446\" value=\"I am happy for a doctor to insert the contraceptive.\">I am happy for a doctor to insert the contraceptive.<\/label><\/div><div class=\"vfb-radio\"><label><input id=\"vfb-field-446-1\" class=\"\" placeholder=\"\" required=\"required\" type=\"radio\" name=\"vfb-field-446\" value=\"I do not want the doctor to insert the contraceptive.\">I do not want the doctor to insert the contraceptive.<\/label><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-checkbox\" id=\"vfbField447\"><label for=\"vfb-field-447\" class=\"vfb-control-label\">Vragen over je gezondheid <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><span class=\"vfb-help-block\">Questions about your health (tick if applicable)<\/span><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-447-14\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-447\" required=\"required\" type=\"checkbox\" name=\"vfb-field-447[14]\" value=\"1\">None of the questions below apply<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-447-0\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-447\" type=\"checkbox\" name=\"vfb-field-447[0]\" value=\"1\">Are you pregnant?<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-447-1\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-447\" type=\"checkbox\" name=\"vfb-field-447[1]\" value=\"1\">Are you 35 years or older and do you smoke?<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-447-2\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-447\" type=\"checkbox\" name=\"vfb-field-447[2]\" value=\"1\">Have you had a heart attack or stroke (CVA)?<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-447-3\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-447\" type=\"checkbox\" name=\"vfb-field-447[3]\" value=\"1\">Do you have a congenital heart disease?<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-447-4\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-447\" type=\"checkbox\" name=\"vfb-field-447[4]\" value=\"1\">Have you had a thrombosis in the legs or a pulmonary embolism?<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-447-5\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-447\" type=\"checkbox\" name=\"vfb-field-447[5]\" value=\"1\">Do you suffer from migraine with aura?<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-447-6\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-447\" type=\"checkbox\" name=\"vfb-field-447[6]\" value=\"1\">Are you known to have a blood coagulation disorder?<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-447-7\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-447\" type=\"checkbox\" name=\"vfb-field-447[7]\" value=\"1\">Do you use anticoagulants to prevent thrombosis?<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-447-8\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-447\" type=\"checkbox\" name=\"vfb-field-447[8]\" value=\"1\">Are you known to have high blood pressure?<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-447-9\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-447\" type=\"checkbox\" name=\"vfb-field-447[9]\" value=\"1\">Have you had a hormone-dependent (breast or uterine) cancer?<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-447-10\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-447\" type=\"checkbox\" name=\"vfb-field-447[10]\" value=\"1\">Do you have diabetes associated with vascular abnormalities?<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-447-11\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-447\" type=\"checkbox\" name=\"vfb-field-447[11]\" value=\"1\">Do you have a serious liver function disorder (such as acute hepatitis)?<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-447-12\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-447\" type=\"checkbox\" name=\"vfb-field-447[12]\" value=\"1\">Do you have unusual vaginal bleeding of which the cause is unknown?<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-447-13\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-447\" type=\"checkbox\" name=\"vfb-field-447[13]\" value=\"1\">Have you used growth hormone?<\/label><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><\/div> <!-- .vfb-well --><div class=\"vfb-well vfb-col-12\" id=\"vfbField448\"><div class=\"vfb-form-group vfb-col-12\"><div><div class=\"\"><\/div><\/div><\/div><div class=\"vfb-col-12 vfb-fieldType-heading\" id=\"vfbField448\"><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-captcha\" id=\"vfbField450\"><div class=\"vfb-form-group\"><div><div class=\"g-recaptcha-v3\" data-sitekey=\"6LdaVKwpAAAAAJJS2gHjtFFboOB5PN9_fuyUw9FK\"><\/div><input type=\"hidden\" name=\"_vfb_recaptcha_enabled\" value=\"1\" id=\"\"><input type=\"hidden\" id=\"g-recaptcha-response\" name=\"g-recaptcha-response\"><div class=\"vfb-has-error\" id=\"vfb-recaptcha-error\"><span class=\"vfb-help-block\">reCAPTCHA is required.<\/span><\/div><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-submit\" id=\"vfbField451\"><button id=\"vfb-field-451\" class=\" btn btn-primary\" placeholder=\"\" type=\"submit\" name=\"_vfb-submit\">Submit <\/button><\/div><div class=\"vfb-clearfix\"><\/div><\/div> <!-- .vfb-well --><\/form>    <\/div>\n<\/div>\n<!-- \/module text -->        <\/div>\n                        <\/div>\n        <\/div>\n        <\/div>\n<!--\/themify_builder_content-->","protected":false},"excerpt":{"rendered":"<p>Decision aid form Use our decision aid and indicate your preferences \u00a0 In preparation for the consultation, please fill in the decision form below so that we can give you tailored advice. Top of form<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"inline_featured_image":false,"footnotes":""},"class_list":["post-2912","page","type-page","status-publish","hentry","has-post-title","has-post-date","has-post-category","has-post-tag","has-post-comment","has-post-author",""],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.5 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Keuzehulpformulier - Abortuskliniek Stimezo - Tel. 038-4217000<\/title>\n<meta name=\"description\" content=\"Maak gebruik van onze keuzehulp en geef uw voorkeuren aan. Zo kunnen de professionals van abortuskliniek Stimezo u een advies op maat bieden.\" \/>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/www.stimezo-zwolle.nl\/en\/decision-aid-form\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Keuzehulpformulier - Abortuskliniek Stimezo - Tel. 038-4217000\" \/>\n<meta property=\"og:description\" content=\"Maak gebruik van onze keuzehulp en geef uw voorkeuren aan. 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