Personal details

First Name ^*

Last Name ^*

Any previous last name(s) ^*

What gender do you identify as?

If other, please specify

Date of birth ^*

Day

Month

Year

NHS number

Home/registered address ^*

Postcode ^*

Do you have an email address? ^*

Yes No

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 throughout your pregnancy and postnatal care; 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.

Telephone number ^*

Tick this box if you would prefer that a midwife does not leave messages on your voicemail.

Accessibility and communciation

Do you need an interpreter?

Yes No

If yes, for which language?

Do you have any physical disability access needs that we need to be aware of?

Yes No

Please provide details of your physical disability

Do you have any learning disabilities?

Yes No

Please provide details about your learning disability

Hearing impairment

Do you have a hearing impairment?

Yes No

If yes, please select any relevant option(s) from the list below:

I can lip read

I use a hearing aid

I need access to a hearing loop

I use Makaton

I use British Sign Language (BSL)

I need visual alerts

Other hearing support/access needs

Visual impairment

Do you have a visual impairment?

Yes No

If yes, please select any relevant option(s) from the list below:

I need information verbally

I need a third party to read out written information

I need an audible alert

I need a tactile (physical) alert

Other visual support/access needs

Letters

Do you need letters in an accessible format?

Yes No

If yes, please select any relevant option(s) from the list below:

Easy read

Large font

Braille

Other format preferences

Accessibility at your appointment

Do you have any communication accessibility requirements when attending your appointments?

Yes No

If yes, please select any relevant option(s) from the list below:

I use a personal communication passport

I use a communication device

I need someone to attend the appointment with me

Other communication accessibility requirements

GP (Doctor) details

If you do not have a GP type ‘None’ in each box below

GP name ^*

GP surgery address ^*

Current pregnancy information

First day of last period

Day

Month

Year

Date of last period Unknown

Have you started taking Folic Acid? ^*

Yes No

If no, please contact your GP, if you have one, for the GP to let you know the dosage that is right for you and start taking the Folic Acid as soon as the dosage is confirmed

If you have registered your pregnancy at another hospital, please share which hospital:

Is this your first pregnancy?

Yes No

If no, how many previous pregnancies have you had?

Do you smoke?

Any known previous pregnancy or labour related conditions

Do you have any known previous pregnancy or labour related conditions?

Yes No

This information will enable us to work together to plan your care - Please select the conditions that you have experienced:

Baby abnormality/ies

Bereavement / miscarriage

Caesarean section

Pre-eclampsia / Eclampsia

Placenta accreta

Premature baby

Shoulder dystocia

Womb surgery

Medical history

We recommend, if you have a GP, that you arrange to see them if you are on medication or have pre-existing medical conditions

Please tick any of the following that apply to you:

Allergies

Please give details of your allergies

Autoimmune disease

Please give details of your auto-immune disease

Blood-related disorder(s)

Please give details of your blood-related disorder

Deep vein thrombosis

Diabetes

Please select the option that applies to you:

Type 1 Type 2 Previous gestational diabetes

Epilepsy

Heart disease

High blood pressure

Hormone disorder(s)

Please give details of your hormone disorder

Kidney disease

Liver disease

Severe asthma

Tuberculosis

None of the above

Please add any additional information that you would like to share about your medical history

Social complexities

Please tick any of the following that apply to you:

Alcohol-related concerns

Domestic abuse concerns

Social worker support

Substance misuse concerns

More about me

What I'd like you to know about me