Register

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?