NOTIFICATION OF PREGNANCY
GP Address
GP Name
Hospital Number
Marital Status M.D.S.
NHS Number
Title:
First Name
Surname:
Previous Surname
Date of birth:
Age
Telephone
number
Home:
Work:
Mobile:
Emergency:
Overseas Visitor .........................................................................
Asylum Seeker ...........................................................................
Date of Arrival in UK ...................................................................
Interpreter Needed......................................................................
Language: ..................................................................................
Address
Email:
Gravida
Para
Miscarriages
Terminations
LMP
EDD
Over 12 Week Pregnant
Previous History (Please  where relevant):
Obstetric History
Medical History
Yes/No
Social Information
Normal
Hypertension
Social Services involvement in past
Pre-eclampsia /Eclampsia
Recurrent urinary infection
Previous child protection concerns
Small for gestational age
Asthma
Domestic abuse/violence:
Rhesus antibodies
Tuberculosis
Caesarean Section
Diabetes
Forceps/Ventouse Delivery
Cardiovascular
Stillbirth
Epilepsy
Consent to share information; Yes/No
Neonatal death
Drug/alcohol addiction
Disability (State)
Congenital abnormality
Psychiatric history
Prematurity (less 36 weeks)
Renal disease
Late Miscarriage
Liver disease
Other
DVT/VTE
Haemoglopinopathy
Other
Substance misuse
Smoker
Other please give an outline
Referring BP
BMI > 35
WT > 100kgs
Current Medication
Anticipated Payment by Results Pathway
Standard()
Intermediate)
Intensive)
Please FAX or email To be confirmed
GP Signature ……………………………………………………………… Date……………………………………………
Print name / Designation …………………………………………………
v0.4: August 2012NHSW
Additional Clinical Information (free text)
For Office Use:
Referral Date
Date Received
Accepted Y/N
Refused
Y/N
If yes reason for refusal (free text)
Date of booking appointment
Date of scan appointment.