General First Name: * Middle Name: Last name: * Date of birth: * Postal Code: * Residence: * Telephone number: * E-mail: * Marital status: * —Please choose an option—UnmarriedLegally MarriedRegistered PartnershipWidowedDivorced Identification Type: —Please choose an option—PassportID cardDrivers licenseResidence documentOther (State by number please) Document number: Length (in cm): Weight before pregnancy (In Kg): BSN (Citizen Service Number): Insurer: Policy number: General practitioner: Health Select what applies to you. I: ... SmokeDrink alcohol sometimesHave ever used drugsSometimes suffer from cold soresEver been treated for an STDUse medicationHave an allergyWas once seriously illEver had surgeryEver had a blood transfusion Health Partner Select what applies to your partner. My partner: ... SmokesSometimes suffers from cold soresIs otherwise healthy Family history Woman Select what applies to your family. My family is familiar with: … Hereditary defectsHigh bloodpressureDiabetesTwinsTuberculoses Family history Partner Select what applies to your partners family. My partners family is familiar with: … Hereditary defectsHigh bloodpressureDiabetesTwinsTuberculoses Previous Pregnancies State below the date, place, gender, weight, and any details of previous pregnancies, miscarriages and / or abortions. Current Pregnancy What was the first day of the last menstrual period?