Make an appointment Houten Personal data First name Last name Date of birth BSN Marital status MarriedRegistered partnershipLATSingleOtherwise Spoken language Address details Address ZIP code Place Contact information Phone number Cell phone number Email address General practitioner and pharmacy General practitioner Pharmacy Insurance details Name of insurance Insurance number Personal data of partner First name Last name Date of birth Contact information Cell phone number Obstetric medical history When was the first day of your last period? Did you have a regular cycle? Yes No If so, how many days? Did you use contraception before you became pregnant? Yes No If so, what form? When did you stop using it? Number of pregnancies Number of births Number of miscarriages Number of abortions Planned pregnancy PlannedNot plannedUnwantedNot planned, but desiredUnknown Send