Antenatal self-referral form

How to Refer to Us

Please complete our online form below.

Referral information Page 1

Note: Questions marked by * are mandatory

*This is a mandatory field. Title (Mr, Miss, Mrs, other)

*This is a mandatory field. First name

*This is a mandatory field. Surname

*This is a mandatory field. Date of birth

*This is a mandatory field. Address

*This is a mandatory field. Postcode

NHS number if known

Hospital number if known

Mobile phone number

Can we call you on this number?

Yes
No

If not, please provide an alternative contact number

*This is a mandatory field. Email address (Please write NO if you do not have one)

Can we email you at this address?

Yes
No

GP's name and address including postcode

Telephone

Is an interpreter required? (family members/partners will not be used as interpreters)

Yes
No

If yes, please state preferred language

	Yes	No
Do you have sight problems?
Do you experience hearing loss?

Start date of Last Menstrual Period (LMP): (approximately if unsure)

Did you have any pregnancies in the past?

Yes
No

If yes, how many?

How many children do you have?

Do you smoke?

	Yes	No
Are you or your partner currently taking non prescribed drug/substances?
Have you, your partner or one of your children ever had a social worker?
Do you have any of the following conditions: Diabetes
High blood pressure
Heart condition
Epilepsy
Sickle cell disease
Are you a sickle cell carrier?

If yes please indicate if HbSS or HbSC

	Yes	No
Thalassaemia
Are you a Thalassaemia carrier?

Other (Please specify)

Please give drug and dose information about current medications

Are you taking Folic Acid? Please ask your midwife about the 'Healthy Start Vitamins' that are available

Yes
No

Have you received any antenatal care this pregnancy?

Yes
No

If yes, where?

Other (please specify)

	Yes	No
Have you or your partner ever had depression, anxiety or mental health issues?
Is this an assisted conception pregnancy?

* Spam Guard: What is the next number after 5? Write the number as a word.

	Yes	No
Did you have any of the following conditions in your previous pregnancies? Diabetes
Pre-eclampsia
High blood pressure