Maternity Self Referral Form for Wrightington, Wigan and Leigh

If you have any difficulties using the Maternity booking form, please contact your own GP or local community midwife team.

The information provided will only be accessed by the maternity team in order to protect your confidentiality.  

This is an initial screening form and the information provided will be used to help us decide how to support you and you will be contacted with an appointment, or for further information if needed based on your responses.

Please ensure that you fill in every field marked *

Please complete this form if you intend to have any of your maternity care with Wrightington, Wigan and Leigh. 

Your Personal Details

First Name*

Surname*

Date of birth*

Day*

Month*

Year*

Tel No.*

Email*

Address*

Street Address*

Address Line 2

City*

County

Postcode*

Are you happy to be contacted by text/email about your appointments?
(please check your junk/spam email box for correspondence about your appointment)

Ethnic Origin*

If other, please state:

NHS Number (Your NHS number can be found at www.nhs.uk/nhs-services/online-services/find-nhs-number) 

GP/Surgery Name* 

GP/Surgery Address*

Street Address*

Address Line 2

City*

County

Postcode*

Emergency contact name, relationship and contact details*

Do you require an interpreter/British Sign Language?*

If Yes, for which language?

Do you have any mobility, sight, hearing or other particular needs that we should be aware of to help prepare for your appointment?*

If yes, please give details:

Have you already received maternity care in a different hospital or privately for this pregnancy?*

Your Pregnancy

The following questions help us to understand your situation, when you will need your first scan, and what kind of maternity care you might need. Please answer as best you can. We will discuss your responses further at your first appointment.

When was the first day of your last menstrual period (when you started your period?)*

Day*

Month*

Year*

Have you had a scan in this pregnancy?*

If you have had a scan, how many babies are you expecting?

Is this an IVF pregnancy?*

Please bring details of your IVF treatment to your first appointment and scan.

About Your Health

What is Your Height*

What is Your Weight*

Are you taking any long term medication?* 

If yes, please give details:

Do you have any of the following conditions:

If other, please specify:

Are you a smoker/do you vape?

Have you commenced taking folic acid?

Have you commenced taking vitamin D?

Previous Pregnancies

Sadly, sometimes a previous pregnancy can end in a loss. We offer bereaved parents special support in later pregnancies, as this can be a difficult and stressful time.

Have you been pregnant before?*

If yes, how many times have you been pregnant?

Have you ever given birth to a baby more than 24 weeks into the pregnancy, who died before birth?*

Have you ever lost a baby shortly after birth?*

Have you ever had complications in a previous pregnancy?

If yes, please give details:

Have you ever had a caesarean birth?*

Your Mental Health

Mental health in pregnancy is just as important as physical health. We have special teams of midwives and doctors to provide support for parents with mental health difficulties.

Have you or your partner ever had depression, anxiety or other mental health issues?*

If yes, please provide any details including any medication that you take/have taken previously:

Your Home Life

We understand that these questions may be sensitive. Please answer honestly so that we can arrange extra support for you and your family.

Have you, your partner or any of your children ever had a social worker?*

If yes, please provide details:

Have you or your partner ever been dependant on drugs or alcohol?*

If yes, please provide details:

Your Care Preferences

Do you know where you would like to give birth?*

If other, please state which one:

Is there anything else you would like to add to this form?

Professional Use Only

If you are a professional submitting this form on behalf of the pregnant woman, please complete the following details:

Name and role of person completing this form

Contact details of person completing the form

Royal Albert Edward Infirmary
Royal Albert
Edward Infirmary
Wrightington Hospital
Wrightington
Hospital
Leigh Infirmary
Leigh
Infirmary
Thomas Linacre Centre
Thomas Linacre
Centre
Community Care Locations
Community
Services
Patient Advice & Liaison Service
Patient Advice
& Liaison Service

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