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SELF-REFERRAL FOR BOOKING INTO MATERNITY SERVICES

Please complete all relevant fields. Failure to do so may slow down the process of making your first appointment.

PLEASE SHARE WITH US ANY INFORMATION WHICH MAY AFFECT THE CARE OF YOU AND YOUR BABY!

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Personal details

Title : *
Name: *
Maiden name:
Date of birth: *
NHS number: *
Address: *
E-mail address: *
Are you happy to be contacted by e-mail? *
Your family origin: *
Father of baby’s family origin: *
Marital status: *
Is English your first language? *
Do you require an interpreter? *
If yes, what language? *
Mobile phone number: *
Are you happy to be contacted by mobile? *
Text? *
NHS messages? *
Home phone number:
Name of your next of kin: *
Phone number of next of kin: *
Are there any dates when you cannot attend the first booking appointment? *
Do you have any disability?  *
If yes, please give details: *
Where have you lived in the last 12 months?  *
Can you show you have the right to receive public benefits in the UK? *
General Practice Name: *
Practice Address: *
General Practitioner Name: *
General Practitioner Email:
Previous pregnancies

Total numbers of pregnancies, including present one, miscarriages and terminations: *
Please record any past delivery details in the table below:
Year of delivery Place of delivery Vaginal birth or Caesarean Delivery
Did you have previous pregnancy diabetes? *
Did you have previous still birth or neonatal death? *
Did you have any high blood pressure problem during previous pregnancies? *
Did you have previous obstetric cholestasis? *
Number of miscarriages before 12 weeks: *
Number of miscarriages after 12 weeks: *
Number of terminations: *
Did you have a previous preterm birth (less than 37 weeks)? *
If yes, please give details:  *
Did you have any other issues during previous pregnancies? *(please give details)
please give details:  *
Current pregnancy

Do you remember 1st day of your last period? *
1st day of your last period: *
Have you had antenatal care elsewhere? *
If yes, please give name of Hospital: *
Estimated due date (if you know):
ANY CURRENT ISSUE RELATING TO THIS PREGNANCY (E.G. TWINS, IVF, TYPE 1 OR TYPE 2 DIABETES): *
Medical history

Have you ever experienced any of the following medical condition in the past or currently?
Do you take any regular medication (Please give details)? *
Cardiac (heart) problem: *
High blood pressure: *
Blood disorder (Sickle cell/Thalassaemia):  *
Haematology (blood) problem:  *
Thyroid problem: *
Neurological (brain) problem: *
Respiratory (chest) problem *
Epilepsy: *
Diabetes *
Renal (kidney) problem:  *
Liver disease: *
Do you currently smoke cigarettes or use e-cigarettes? *
PLEASE GIVE DETAILS IF YOU ANSWERED YES TO ANY MEDICAL CONDITION (failing to do so, might result in your appointment being delayed):
Mental health history

Anxiety or Depression:  *
Schizophrenia or Bipolar:  *
Have you attempted suicide in the last 2 years?  *
Have you been sectioned or admitted to a mental health unit following mental health issues or under the care of a Community Mental Health Team in the last 5 years?  *
PLEASE GIVE DETAILS IF YOU ANSWERED YES TO ANY MENTAL HEALTH HISTORY (failing to do so, might result in your appointment being delayed):
Social history

Do you have a social worker or have you been supported by a social worker in the last 2 years?  *
Have you or your child(ren) been on a child protection or child in need plan?  *
If yes, please give details:  *
Are you seeking asylum?  *
Do you currently have an allocated case worker?  *
Are your children living with you? *
Have you experienced any Domestic Abuse/Domestic Violence in the last 2 years?  *
Since becoming pregnant have you taken or do you currently use any recreational drugs?  *
Have you ever attended a special needs school?  *
Do you currently drink >14 units of alcohol a week?  *
PLEASE GIVE DETAILS IF YOU ANSWERED YES TO ANY SOCIAL HISTORY (failing to do so, might result in your appointment being delayed):

Please download free Baby Buddy app on your phone before your booking appointment, this will be part of your care package.