Maternity self referral form 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 *This is a mandatory field. Date of birth *This is a mandatory field. Address *This is a mandatory field. Postcode NHS number if known Hospital number if known Mobile phone number Can we call you on this number? Yes No NA 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 NA GP's name and address including postcode Telephone Is an interpreter required? (family members/partners will not be used as interpreters) Yes No NA If yes, please state preferred language Yes No NA Do you have sight problems? Do you experience hearing loss? Start date of Last Menstrual Period (LMP): (approximately if unsure) Did you have any pregnancies in the past? Yes No NA If yes, how many? How many children do you have? Do you smoke? Yes No NA 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 Epilepsy Sickle cell disease Are you a sickle cell carrier? If yes please indicate if HbSS or HbSC Yes No NA Thalassaemia Are you a Thalassaemia carrier? Other (Please specify) Please give drug and dose information about current medications Are you taking Folic Acid? Please ask your midwife about the 'Healthy Start Vitamins' that are available Yes No NA Have you received any antenatal care this pregnancy? Yes No NA If yes, where? Yes No NA Did you have any of the following conditions in your previous pregnancies? Diabetes Pre-eclampsia High blood pressure Other (please specify) Yes No NA Have you or your partner ever had depression, anxiety or mental health issues? Is this an assisted conception pregnancy? What is your sexual orientation Please Select An Option HeterosexualHomosexualBisexualQueerPrefer not to say Question 48
