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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
Last name:
First name:
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Known as:
Date of birth:
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Title:
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Select
Mr
Mrs
Miss
Ms
Dr
Prefer not to say
Other
If you wish, share your pronouns (eg. she, her, he, him, they, them):
Your ethnicity:
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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
Mobile telephone number:
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Other Ethnic group:
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Aternative telephone number:
May we contact you by text message?
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Yes
No
Email address:
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NHS number:
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Home address and postcode:
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How long have you lived here?
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Are you a UK resident?
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Yes
No
Why this question is asked
Are you a refugee or asylum seeker?
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Yes
No
Do you read and write English?
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Yes
No
Do you require a translator or British Sign Language? (The NHS does not recommend use of family members to translate):
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Yes
No
Let us know any dates you are unable to attend for your first appointment:
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What is your preferred language?
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Do you have a learning difficulty or a disability that we should know about?
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Yes
No
Your support network
Emergency contact number:
Next of kin:
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Their relationship to you:
GP's name:
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Are you member of the Armed Forces community?
Yes
No
General Practitioner Name:
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Select
GP surgery address:
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GP surgery phone number:
Pregnancy and maternity history
What was the date of the first day of your last period, or the date of embryo transfer?
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Is this the first time you have been pregnant?
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Yes
No
Have you had antenatal care elsewhere in this pregnancy?
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Yes
No
If yes, where?
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Number of vaginal births:
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Number of caesarean births:
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Number of instrumental births (e.g ventouse, kiwi cup, forceps):
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Have you given birth to a live baby BEFORE 37 weeks? If so, how many weeks pregnant were you?
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We understand the following questions may be difficult for you, but your answers will help us to provide the best care during this pregnancy:
Have you ever had a termination of pregnancy?
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Yes
No
Have you ever lost (miscarried) a baby before 12 weeks gestation?
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Yes
No
Have you lost (miscarried) any babies between 12 and 24 weeks?
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Yes
No
Have you had any babies that were stillborn? How many weeks pregnant were you?
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Have you had any babies born alive, who have since died? How old were they?
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Did you have any medical problems in a previous pregnancy, during labour, or after the birth of your baby (eg. gestational diabetes, high blood pressure, pre-eclampsia, itching, severe bleeding)?
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Please give as much detail as you can.
Your medical history
In your whole life, have you ever had, or still have, a LONG-TERM MEDICAL or MENTAL HEALTH condition?
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Yes
No
Heart condition (eg. birth defect):
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High blood pressure?
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Yes
No
Kidney condition? (eg.recurrent urinary tract infections):
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Stomach, bowel or liver condition? (eg. inflammatory bowel disease, Crohn's)
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Blood condition? (eg sickle cell/thalassaemia, blood clots)
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Endocrine condition? (eg. Type 1 or Type 2 diabetes, thyroid disease)
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Neurological condition? (eg. epilepsy, stroke, mutiple sclerosis)
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Breathing difficulty? (eg. asthma)
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Autoimmune condition? (eg. lupus, arthritis)
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A skin condition? (eg. eczema, psoriasis)
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Cancer?
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Mental health & wellbeing concerns? Please provide details.
Anything else, not mentioned above?
Medication (prescribed or over the counter medicines):
The NHS recommends a daily dose (400mcg) of Folic Acid. Some people may need a higher dose. Find out more by reading the
link
.
Are you taking MEDICATION for ANY medical or mental health condition? If so, please list ALL the medications & dosages here, including any supplements (vitamins)
Personal circumstances: we understand that these questions are sensitive. Please answer honestly so that we can arrange extra support where necessary for you and your family:
Have you (or any of your children) ever had, or still have, a social worker? If so, please give the name and telephone number of the social worker
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Have you ever experienced domestic violence? If yes, please give details
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Have you ever used recreational drugs? If so, describe what drugs you use(d) and how often.
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Is there anything else that you think we should know to support you during pregnancy, birth or after your baby is born?
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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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