Maternity self referral form

Referral information Page 1

Note: Questions marked by * are mandatory

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

  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
Sickle cell disease
Are you a sickle cell carrier?
  Yes No
Are you a Thalassaemia carrier?

  Yes No
Did you have any of the following conditions in your previous pregnancies? Diabetes
High blood pressure
  Yes No
Have you or your partner ever had depression, anxiety or mental health issues?
Is this an assisted conception pregnancy?