Antenatal self-referral form

Screening information for you and your baby

Read the online Screening tests for you and your baby information before your midwife booking appointment to find out more about the screening tests and scans offered.

Scan the QR code or click on the link below

QR code for screening information

Screening tests for you and your baby (STFYAYB) - GOV.UK (www.gov.uk)

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

Previous surnames

*This is a mandatory field. Date of birth

*This is a mandatory field. Full Address

*This is a mandatory field. Postcode

NHS number if known

Hospital number if known

*This is a mandatory field. Mobile phone number

Can we call you on this number?

Yes
No
N/A

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
N/A

*This is a mandatory field. GP's name and address including postcode

Telephone

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

Yes
No
N/A

If yes, please state preferred language

*This is a mandatory field. Start date of Last Menstrual Period (LMP): (approximately if unsure)

Did you have any pregnancies in the past?

Yes
No
N/A

If yes, how many?

How many children do you have?

Do you smoke?

	Yes	No	N/A
Are you or your partner currently taking non prescribed drug/substances not including vitamins?
Have you, your partner or one of your children ever had a social worker?
Do you have any of the following conditions when you are not pregnant: Diabetes
High blood pressure
Heart condition
Epilepsy
Sickle cell disease
Are you a sickle cell carrier?

If yes please indicate if HbSS or HbSC

Have you ever had a deep vein thrombosis (DVT) or pulmonary embolism confirmed by a scan?

Yes
No

Do you have nausea or vomiting severe enough to cause one of the following? (It is normal to have some nausea & vomiting in early pregnancy, but sometimes it can be severe)

you cannot drink without vomiting
you struggle to stand up or walk due to nausea

	Yes	No
Is your BMI over 50?
Are you currently taking one of these anticoagulants: warfarin, apixaban, rivaroxaban, dabigatran or edoxaban?
Have you been diagnosed with antithrombin deficiency (a disorder that makes blood clots more likely)?

Please give drug and dose information about current medications

Have you received any antenatal care this pregnancy?

Yes
No
N/A

If yes, where?

Other (please specify)

Is this an assisted conception pregnancy?

Yes
No
N/A

Estimated date of Delivery (EDD)

What is your sexual orientation

Antenatal self-referral form

Search the Homerton Healthcare NHS Foundation Trust website