Antenatal self-referral form
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Maternity services
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?
Yes
No
Did you have any of the following conditions in your previous pregnancies? Diabetes
Pre-eclampsia
High blood pressure
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.