Please state whether you are: Please state whether you are: Pregnant Woman GP

Preferred Title Preferred Title Ms Mrs

*First Name

*Surname

Any previous surnames

*Date of Birth

*NHS number

*Email Address

*Confirmation of email address

Home Phone Number

*Mobile Phone Number

*Address

*Name of GP surgery

Address of GP surgery including postcode

*What is your primary language?

If English is not your primary language do you require an interpreter? If English is not your primary language do you require an interpreter? Yes No

*Country of Birth

*Ethnic origin *Ethnic originWhite BritishWhite IrishAny other white backgroundMixed White and Black CaribbeanMixed White and Black AfricanMixed White and AsianAny other mixed backgroundAsian IndiaAsian PakistaniAsian BangladeshiAny other asian backgroundBlack CaribbeanBlack AfricanAny other black backgroundChineseAny other Chinese backgroundAny other ethnic origin – please specify belowPrefer not to say

Your ethnic origin if it has not been listed above (optional)

*First day of last period (DD/MM/YYYY)

How many days on average is your usual menstrual cycle?

Have you had an ultrasound scan yet this pregnancy? Have you had an ultrasound scan yet this pregnancy? Yes No

If yes, what date was this scan:

Do you know if this is a twin / multiple pregnancy? Do you know if this is a twin / multiple pregnancy? Yes No

Is this an IVF pregnancy? Is this an IVF pregnancy? Yes No

If yes what is the embryo transfer date and estimated due date?

Are you considering or interested in our home birth service? Are you considering or interested in our home birth service? Yes No Need more information Undecided

Estimated Due Date

Current Hospital

Any current pregnancy concerns

Have you been seen for specialist pre-pregnancy counselling or been advised to have a specialist medical review during pregnancy? Have you been seen for specialist pre-pregnancy counselling or been advised to have a specialist medical review during pregnancy? Yes No

If Yes please specify

Do you have a known or suspected haemoglobin variant such as sickle cell or thalassemia? Do you have a known or suspected haemoglobin variant such as sickle cell or thalassemia? Yes No

If Yes please specify

*Have you ever been pregnant before? *Have you ever been pregnant before? Yes No

*Do you have any children? *Do you have any children? Yes No

Previous Birth Dates and Types

Any other details of previous births

Have you ever experienced any of the following in previous pregnancies? Have you ever experienced any of the following in previous pregnancies? Caesarean Section Baby born before 37 weeks Baby born before 28 weeks High blood pressure Pre-eclampsia/ eclampsia Antenatal/ Postnatal depression Miscarriage or termination after 13 weeks Baby born with an abnormality Placenta Accreta Stillbirth or Neonatal death Gestational Diabetes Other (please specify below):

Any other details

Height Height4' 10"4' 11"5' 0"5' 1"5' 2"5' 3"5' 4"5' 5"5' 6"5' 7"5' 8"5' 9"5' 10"5' 11"6' 0"6' 1"6' 2"6' 3"6' 4"6' 5"6' 6"

Weight

BMI

Do you smoke? Do you smoke? Yes No

If yes please tick this box if you would like to be referred to the smoking cessation team to give you support and information regarding stopping smoking in pregnancy If yes please tick this box if you would like to be referred to the smoking cessation team to give you support and information regarding stopping smoking in pregnancy Yes

Have you ever been under the care of a psychiatrist? Have you ever been under the care of a psychiatrist? Yes No

Do you currently take any regular medication? Do you currently take any regular medication? Yes No

If yes please specify medicine and dose

Are you a type 1 or type 2 diabetic? Are you a type 1 or type 2 diabetic? Yes No

If yes please specify

Do you suffer with any conditions affecting any of the following Do you suffer with any conditions affecting any of the following Heart Kidneys Liver Immune system (such as HIV) Lungs (including asthma or TB) Neurological (such as epilepsy) Autoimmune (including lupus or rheumatoid arthritis Other (please specify below)

If you have answered yes to any of the above please provide details

Have you ever been diagnosed with any of the following Have you ever been diagnosed with any of the following Cancer Deep vein thrombosis Pulmonary Embolism High blood pressure which has required medication A condition affecting the way your blood clots (such as von willebrands, Factor V Leidan or thrombophilia) Hypothyroidism or Hyperthyroidism (If you currently or previously suffered with either of these please attend your GP surgery ASAP to have blood tests taken for thyroid function.) Other (please specify below)

If you have answered yes to any of the above please provide details