Booking your first midwife appointment

Booking information

First name:

Last name:

Name(s) previously known by:

Title 

MrMrsMissMsDrOther

Date of birth (DD/MM/YYYY):

Ethnicity 

White- BritishWhite – IrishAny other white backgroundMixed- white and black CaribbeanMixed- white and black AfricanMixed-white and AsianAny other mixed backgroundAsian-Indian or British IndianAsian-Pakistani or British PakistaniAsian-Bangladeshi or British BangladeshiAsian – Any other Asian backgroundBlack – Caribbean or black British CaribbeanBlack – African or British AfricanBlack – any other black backgroundChineseAny other ethnic group

Address: 

Postcode

Have you lived in the UK for the past 12 months?

YesNo

Telephone (home):

Telephone (mobile): 

NHS number (if known)

Hospital number (if known)

Do you require an interpreter at the appointment?  

YesNo

Which language is required? 

Name of GP

GP practice 

Name of next of kin

Telephone number of next of kin

Do you have any preferred days? or any dates you are unavailable to attend.  i.e. holidays, working days. We will do our best to accommodate your request, however due to the increase in pregnancies and business of the base we are not always able to.
Bookings appointments can be done up to your 12th week of pregnancy,  however if your appointment is after your 12th week we will inform the midwife team you will be under to either bring your appointment forward or call you to discuss screening and scan options. 

Previous history

If this is your first pregnancy please move on to the next section. 

Number of previous pregnancies

Number of previous deliveries

Place of birth(s)

Date of birth(s)

Type of birth(s)

Any known complications?

This pregnancy

First day of last menstrual period LMP (if known)

Have you had a scan during this pregnancy? 

YesNo

If you answered yes, what date and where did the scan take place? How many weeks was the pregnancy dated at?

Where would you like to have your baby?

St MichaelsSouthmeadRUHOther

Please tell us about any known medical conditions

Please tell us about any medication you are currently taking

Do you smoke, or have you quit smoking in the last 2 weeks?

YesNo

The best way of stopping smoking is with the help of a trained stop smoking advisor. Would you like to talk to your local stop smoking service about the support available to you?

YesNo