Name(s) previously known by:
Date of birth (DD/MM/YYYY):
Have you lived in the UK for the past 12 months?
NHS number (if known)
Hospital number (if known)
Do you require an interpreter at the appointment?
Which language is required?
Name of GP
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.
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?
First day of last menstrual period LMP (if known)
Have you had a scan during this pregnancy?
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?
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?
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?
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