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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!
*
denotes mandatory fields
Personal details
Title:
*
Select
Mrs
Ms
Miss
First name:
*
Surname/Family name:
Maiden name or any other Surname/Family name:
Date of birth:
*
NHS number:
*
Address:
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Postcode:
*
Height (metres/cm's):
*
Select
metres
cm's
Weight (kg's):
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E-mail address:
*
Are you happy to be contacted by e-mail?
*
Yes
No
Ethnic group:
*
Select
Arab
Asian - Bangladeshi
Asian - Chinese
Asian - Indian
Asian - Pakistani
Asian - Any other group
Black - African
Black - Caribbean
Black - Any other background
European
Mixed - White and Asian
Mixed - White and Black African
Mixed - White and Black Caribbean
Mixed - Other
White - British
White - Irish
Other - Any other
Other Ethnic group:
*
Father Ethnic group:
*
Select
Arab
Asian - Bangladeshi
Asian - Chinese
Asian - Indian
Asian - Pakistani
Asian - Any other group
Black - African
Black - Caribbean
Black - Any other background
European
Mixed - White and Asian
Mixed - White and Black African
Mixed - White and Black Caribbean
Mixed - Other
White - British
White - Irish
Other - Any other
Other Ethnic group:
*
Marital status:
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Married
Unmarried
Is English your first language?
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Yes
No
Do you require an interpreter/British sign language?
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Yes
No
If yes, language spoken?
*
Mobile phone number:
*
Are you happy to be contacted by mobile?
*
Yes
No
Text?
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Yes
No
NHS messages?
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Yes
No
Home phone number:
Name of your next of kin:
*
Phone number of next of kin:
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Are there any dates when you cannot attend the first booking appointment?
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Do you have any disability?
*
Yes
No
If yes, please give details:
*
Where have you lived in the last 12 months?
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UK Only
Outside UK
State/Country of residence:
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Can you show you have the right to receive public benefits in the UK?
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Yes
No
General Practice Name:
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Practice Address:
*
General Practitioner Name:
*
Select
General Practitioner Email:
Previous pregnancies
Did you have any previous pregnancies (including present one, miscarriages and terminations)?
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Yes
No
Total numbers of pregnancies, including present one, miscarriages and terminations:
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Please record
any
past delivery details in the table below:
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Year of delivery
Place of delivery
Vaginal birth or Caesarean Delivery
Did you have previous pregnancy diabetes?
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Yes
No
Did you have previous still birth or neonatal death?
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Yes
No
Did you have any high blood pressure problem during previous pregnancies?
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Yes
No
Did you have previous obstetric cholestasis?
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Yes
No
Number of miscarriages before 12 weeks:
*
Number of miscarriages after 12 weeks:
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Number of terminations:
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Did you have a previous preterm birth (less than 37 weeks)?
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Yes
No
If yes, please give details:
*
Did you have any other issues during previous pregnancies?
*
(please give details)
please give details:
*
Current pregnancy
1
st
day of your last period:
*
Have you had antenatal care elsewhere?
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Yes
No
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)?
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Cardiac (heart) problem:
*
Yes
No
High blood pressure:
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Yes
No
Blood disorder (Sickle cell/Thalassaemia):
*
Yes
No
Are you a carrier for Sickle cell/Thalassaemia or any variants?
*
Yes
No
Do you have Sickle cell disease (e.g. HbSS, HbSC)?
*
Yes
No
Haematology (blood) problem:
*
Yes
No
Thyroid problem:
*
Yes
No
Neurological (brain) problem:
*
Yes
No
Respiratory (chest) problem
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Yes
No
Epilepsy:
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Yes
No
Diabetes
*
Yes
No
Renal (kidney) problem:
*
Yes
No
Liver disease:
*
Yes
No
Do you currently smoke cigarettes or use e-cigarettes?
*
Yes
No
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:
*
Yes
No
Schizophrenia or Bipolar:
*
Yes
No
Have you attempted suicide in the last 2 years?
*
Yes
No
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?
*
Yes
No
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?
*
Yes
No
Have you or your child(ren) been on a child protection or child in need plan?
*
Yes
No
If yes, please give details:
*
Are you seeking asylum?
*
Yes
No
Do you currently have an allocated case worker?
*
Yes
No
Are your children living with you?
*
Yes
No
Have you experienced any Domestic Abuse/Domestic Violence in the last 2 years?
*
Yes
No
Since becoming pregnant have you taken or do you currently use any recreational drugs?
*
Yes
No
Have you ever attended a special needs school?
*
Yes
No
Do you currently drink >14 units of alcohol a week?
*
Yes
No
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.
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