Pregnancy Pre-Registration / Self-Referral Form

PLEASE COMPLETE ALL SECTIONS OF THIS FORM

Patient details

Are you referring yourself?*

Yes
No

OR

Has a GP already referred you?*

Yes
No

Name*

First Last

Previous Surname

Last

Date of birth*

Hospital No/MRN

(If known)

NHS No

(If known)

Please select your ethnic origin:*

Country of birth (e.g. UK)?*

Do you usually live in the UK?*

Yes
No

Address in the UK*

Street Address Address Line 2 City Town Postcode

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Address OUTSIDE the UK

Street Address Address Line 2 City Town Postcode

Email

Contact number*

Can we contact you on this number by text messaging?*

Yes
No

GP details

Are you registered with a GP in the UK?*

Yes
No

GP Name*

Practice Name*

GP Address*

Street Address Address Line 2 City Town Postcode

Further patient details

Marital Status

Religion

Do you require an Interpreter?*

YES
NO

Language spoken*

Where would you like to have your baby?

Pregnancy history

First day of your last menstrual period (LMP)?*

How many weeks pregnant are you? (months and weeks)

How many weeks pregnant are you?*

Please tell us when your baby is due*

Have you had a scan?

YES
NO

Height

Weight

Have you had any previous pregnancies, including miscarriages and terminations?*

Yes
No

How many previous pregnancies? (Total)*

How many previous terminations?*

Miscarriages before 13 weeks of pregnancy*

Pregnancies losses after 13 weeks of pregnancy*

How many weeks pregnant were you?*

Per-term birth, before 36 weeks gestation?*

Live births*

Have you ever had diabetes in preganancy?*

Have you ever had a baby weighing more than 4kg*

Have you ever had a baby weighing less than 2.5kg*

Have you ever had high blood pressure in pregnancy?*

Excessive bleeding following the birth of your child?*

Caesarean section*

Please provide details and provide us with any other information we should know about your previous pregnancies’*

Past Medical History

Do you currently have, or have you had any other health problems?*

Yes
No

Do you have or have you ever had high blood pressure?*

Yes
No

Do you have or have you ever had heart problems?*

Yes
No

Do you have or have you ever had diabetes?*

Yes
No

Do you have or have you ever had asthma?*

Yes
No

Do you have or have you ever had previous surgery?*

Yes
No

Please provide further details of your medical history:*

Please list any medication you are currently taking:*

Are you a carrier of the sickle cell gene / sickle cell trait?*

Yes
No
Don't know

Are you a carrier of the thalassemia gene / thalassemia trait?*

Yes
No
Don't know

Do you know if the father of the baby has been tested for Sickle cell gene or Thalassemia gene?*

Yes
No
Don't know

Do you have or have you ever suffered from anxiety and/or depression?:*

Yes
No

Please provide any other information about this:*

Are you known to social services?*

Yes
No

If yes, please provide the name and contact number of your social worker

Do you have any communication needs e.g. hearing loss, visual impairment or learning disability?*

Yes
No

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How should we contact you?*

Requires audible alert
Requires contact by email
Requires contact by letter
Requires contact by short message service text message
Requires contact by telephone
Requires contact by text relay

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How should we communicate with you?

This field is hidden when viewing the form

How should we give you information?*

This field is hidden when viewing the form

Do you have any other communication requirements not listed or specified above:*

Do you consent to your communication and information needs being shared or used with any other health and social care provider?*

Hospital Transfer

Are you transferring hospital?*

YES
NO

Have you booked at another hospital?*

YES
NO

Name of hospital/birth centre you are currently booked at*

Next of kin details

Name*

First Last

Next of kin Address*

Street Address Address Line 2 City Town Postcode

Contact number*

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PLEASE COMPLETE ALL SECTIONS OF THIS FORM

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Hospital Transfer

Next of kin details

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