Booking Form Your Details NHI Number* Marital status* Your surname* Partner's name* Your first names* Doctor's name/Practice* Your address* Date of birth* Country of birth* Spoken language* Interpreter required?* Select oneYesNo Work phone Home phone Mobile* Email* Ethnic Group* Occupation* Emergency contact* Emergency contact phone* Your residency status* Are you eligible for free care?* Select oneYesNo Height* Weight* When was your last smear test at the Drs?* Smear result* Are you on the national smear test register?* Select oneYesNo Is this a twin or multiples pregnancy?* Select oneYesNo Did you have assisted fertility treatment?* Select oneYesNo How many children do you have?* How many pregnancies have you had?* First day of last period?* Due Date* Have you have any blood tests in this pregnancy?* Select oneYesNo If yes, where did you have your blood tests done?* Have you had any scans in this pregnancy?* Select oneYesNo If yes, how many?* Where did you have your scan/s?* What is your planned place of birth?* Do you have any history of medical conditions, operations, health problems or a history of gynaecology problems or treatment of your cervix?* Pregnancy So Far Have you had any bleeding* Select oneYesNoUnsure If yes, when?* Stomach Pain?* Select oneYesNo If yes, when?* Do you have severe vomiting?* Select oneYesNo If yes, do you take medicine for this?* Any other concerns* Lifestyle and Circumstances Always smoke free* Select oneYesNo Currently smoking* Select oneYesNo If yes, number per day* Partner smoke free* Select oneYesNo Household smoke free* Select oneYesNo Help to quit smoking?* Select oneYesNo Diabetic?* Select oneYesNo Diet?* Select oneCoeliacVegetarianVeganPoor dietDiabetic dietKetogenicNormalPescatarian Alcohol?* Select oneYesNo Marijuana?* Select oneYesNo Other substances?* Select oneYesNo Pregnancy History Is this your first pregnancy? Select oneYesNo Children Count Miscarriages Caesareans Terminations Ectopic Pregnancies Stillbirths Maternal Medical History Rheumatic Fever* Select oneYesNo Epilepsy* Select oneYesNo Skin Disorder* Select oneYesNo Heart Disease* Select oneYesNo Asthma* Select oneYesNo Autoimmune* Select oneYesNo Hormonal Issues* Select oneYesNo Tuberculosis* Select oneYesNo Infections* Select oneYesNo Thyroid Problems* Select oneYesNo Lung Disorder* Select oneYesNo STD* Select oneYesNo Diabetes* Select oneYesNo Gastro-Intestinal* Select oneYesNo Infertility* Select oneYesNo Genetic Disorder* Select oneYesNo Liver Disorder* Select oneYesNo Psychiatric* Select oneYesNo High Blood Pressure* Select oneYesNo Renal/Kidney Issues* Select oneYesNo Depression* Select oneYesNo Blood Clotting Problems* Select oneYesNo Blood Disorders* Select oneYesNo UTIs/Bladder Infections* Select oneYesNo Previous Anaesthetic* Select oneYesNo Varicose Veins* Select oneYesNo Bone Disorder* Select oneYesNo Birth Defects* Select oneYesNo Neurological Issues* Select oneYesNo Joint Disorder* Select oneYesNo Allergies* Select oneYesNo Maternal History Notes Family Medical History Heart Condition* Select oneYesNoUnsure Cancer* Select oneYesNoUnsure Deafness* Select oneYesNoUnsure Diabetes* Select oneYesNoUnsure Spina Bifida* Select oneYesNoUnsure Malignant Hyperthermia* Select oneYesNoUnsure High Blood Pressure* Select oneYesNoUnsure Clicky Hips* Select oneYesNoUnsure Pre-Eclampsia* Select oneYesNoUnsure Blood Clotting Issues* Select oneYesNoUnsure Cleft Palate* Select oneYesNoUnsure Twins/Triplets* Select oneYesNoUnsure Epilepsy* Select oneYesNoUnsure Cerebral Palsy* Select oneYesNoUnsure Psychiatric Issues* Select oneYesNoUnsure Asthma* Select oneYesNoUnsure Neural Tube Defects* Select oneYesNoUnsure Anxiety/Depression* Select oneYesNoUnsure Tuberculosis* Select oneYesNoUnsure Congenital Conditions* Select oneYesNoUnsure Allergies* Select oneYesNoUnsure Renal/Kidney Issues* Select oneYesNoUnsure Eczema* Select oneYesNoUnsure Medications ' Are you taking Folic Acid?* Select oneYesNo Are you taking Iodine?* Select oneYesNo Please list all medications* Previous Pregnancy Details Previous Pregnancy 1 Date Of Birth Gestation Place of BirthSex SelectMaleFemaleAnenatal Problems SelectYesNoLabour Complications? SelectYesNoType of BirthSVDForcepsVentouseCaesarianBreechOutcomeSelectLiveSBNNDName Feeding (if breastfed give duration)Birth WeightCurrent Health Previous Pregnancy 2 Date Of Birth Gestation Place of BirthSex SelectMaleFemaleAnenatal Problems SelectYesNoLabour Complications? SelectYesNoType of BirthSVDForcepsVentouseCaesarianBreechOutcomeSelectLiveSBNNDName Feeding (if breastfed give duration)Birth WeightCurrent Health Previous Pregnancy 3 Date Of Birth Gestation Place of BirthSex SelectMaleFemaleAnenatal Problems SelectYesNoLabour Complications? SelectYesNoType of BirthSVDForcepsVentouseCaesarianBreechOutcomeSelectLiveSBNNDName Feeding (if breastfed give duration)Birth WeightCurrent Health Previous Pregnancy 4 Date Of Birth Gestation Place of BirthSex SelectMaleFemaleAnenatal Problems SelectYesNoLabour Complications? SelectYesNoType of BirthSVDForcepsVentouseCaesarianBreechOutcomeSelectLiveSBNNDName Feeding (if breastfed give duration)Birth WeightCurrent Health Previous Pregnancy 5 Date Of Birth Gestation Place of BirthSex SelectMaleFemaleAnenatal Problems SelectYesNoLabour Complications? SelectYesNoType of BirthSVDForcepsVentouseCaesarianBreechOutcomeSelectLiveSBNNDName Feeding (if breastfed give duration)Birth WeightCurrent Health Previous Pregnancy 6 Date Of Birth Gestation Place of BirthSex SelectMaleFemaleAnenatal Problems SelectYesNoLabour Complications? SelectYesNoType of BirthSVDForcepsVentouseCaesarianBreechOutcomeSelectLiveSBNNDName Feeding (if breastfed give duration)Birth WeightCurrent Health Add Previous PregnancySubmit
