Your Care Preferences

https://www.mybirthmychoice.co.uk/

Do you know where you would like to give birth?* Royal Albert Edward Infirmary (Wigan)Home BirthOther hospital

If other, please state which one:

Your Personal Details

Your Full Name*

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? YesNo

Country of Birth?

Ethnic Origin* SelectWhite BritishWhite IrishBlack AfricanWhite black AfricanWhite & black CaribbeanAsian other backgroundBlack CaribbeanBangladeshiIndianPakistaniChineseWhite and AsianOther black backgroundOther mixed backgroundOther white background

If other, please state:

NHS Number   If you don't know your NHS number it can be found here

GP/Surgery Name* 

GP/Surgery Address*

Street Address*

Address Line 2

City*

County

Postcode*

Emergency contact name, relationship and contact details*

Is your first language English?* YesNo

*Please note that a family member / friend can be present at your appointment, but they cannot be used to translate on your behalf*

Do you require an interpreter?* YesNo

If yes, what language? 

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

If yes, please give details:

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

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?* YesNo

If you have had a scan, how many babies are you expecting? Don’t knowYes 1Yes 2Yes 3More than 3

Is this an IVF pregnancy?* YesNo

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?* YesNo

If yes, please give details:

Do you have any of the following conditions: EpilepsyKidney ProblemsHeart ProblemsLung ProblemsBowel ProblemsBlood DisordersType 1/Type 2 DiabetesEndocrine Disorders (e.g. Thyroid)Previously had a blood clot in your legs or lungs (Venous Thromboembolism/Deep Vein Thrombosis/Pulmonary Embolismconditions_sickle_cell Sickle Cell Disease/CarrierThalassaemia/CarrierHepatitis B/HIV/SyphilisLearning DisabilityOther relevant medical or surgical history

If other, please specify:

Are you a smoker? YesNo

Have you commenced taking folic acid? YesNo

Have you commenced taking vitamin D? YesNo

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?* YesNo

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?* YesNo

Have you ever lost a baby shortly after birth?* YesNo

Have you ever had complications in a previous pregnancy? YesNo

If yes, please give details:

Have you ever had a caesarean birth?* YesNo

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?* YesNo

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?* YesNo

If yes, please provide details:

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

If yes, please provide details:

Further Information

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

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