Personal details

Where do you plan to have your baby? ^*

William Harvey Hospital Ashford

Queen Elizabeth Queen Mother Hospital Margate

Home birth

First name ^*

Surname ^*

Maiden name

Date of birth (dd/mm/yyyy) ^*

NHS number

Address ^*

Postcode ^*

Email address ^*

Please be aware the email address you have entered will be added to your hospital record and we will use it to contact you about accessing MOMA; we strongly advise this email address is your own personal email and does not belong to anyone else. Your details will not be shared with any third party or used for marketing.

Email address again ^*

Telephone number ^*

If you are not happy for a midwife to leave a message on your voicemail, click here

I need an interpreter

Yes

Language

Mother's ethnic group ^*

Father's ethnic group (if known)

Mother's nationality ^*

What gender do you identify as? ^*

Other

Title

GP details

GP Name

GP Address ^*

GP telephone number ^*

Current pregnancy information

First day of last period (dd/mm/yyyy)

Number of previous deliveries

If booked at another hospital which

Reason if booking after 12 weeks pregnant

Previous pregnancies

This information will enable us to work together to plan your care

Having first baby

Caesarean Section

Pre-Eclampsia/Eclampsia

Miscarriage after 13 weeks

Placenta Accreta

Premature baby

Postnatal depression

Baby born with abnormality

Stillbirth

Previous womb surgery

3 or more miscarriages

Shoulder Dystocia

Neonatal death

Other (please give details)

Medical history

High blood pressure

Epilepsy

Liver disease

Autoimmune disease

Tuberculosis

Diabetes

Heart disease

Severe asthma

Other hormone disorder

Kidney disease

Blood clotting disorder

Deep vein thrombosis

Female Genital Mutilation

Haemoglobin disorder

Any mental health concerns

Other (please give details)

General information

Smoker

Learning disability

Please give details of any alcohol or substance use

Please give details of any domestic violence

Children on protected register

Name of Social Worker (if any)

Current medication

Allergies

Other domestic or social circumstances (please give details)

What I would like you to know about me…

maternity-referral