Antenatal appointment request

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Postcode: *

Have you been pregnant before? (Including pregnancy loss?) *

Yes

No

Current Pregnancy Information:

First day of your last period (if known):

DD/MM/YYYY

How far along do you believe your pregnancy is (in weeks):

Have you thought about where you would like to birth your baby? (Hospital, home birth?)

Social History

Have you ever had support from a social worker or family support worker?

Yes

No

Do you smoke?

Yes

No

Do you currently drink more than 14 units of alcohol a week?

Yes

No

Medical History

Do you take regular medications?

Yes

No

Have you ever suffered with any mental health concerns, such as depression or anxiety?

Yes

No

Have you ever experienced diabetes?

Yes

No

Height:

Weight:

Terms and Conditions

Please note that your request will now be assessed by the midwife. This may result in a receptionist calling you to arrange an appointment, or the GP may call you to attempt to deal with your medical issue. If necessary a face to face appointment can be arranged after this call.

By pressing submit the form is sent to The Hollies Medical Practice. We aim to respond to all enquiries within 48 hours of receipt (excluding weekends).

Our primary means of contacting you is via SMS or email. If you provide your email address, you will receive automatic confirmation in your email when your contact request has been delivered. Thank you.

*

I understand this is a non-urgent request form. I agree that I will contact NHS 111 or 999 if my symptoms become urgent. I understand that general practice cannot deal with life threatening care needs.

*

I have read the terms and conditions and agree with the guidelines set out.

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Current Pregnancy Information:

Social History

Medical History

Terms and Conditions