WGN500432

Brighton and Sussex

Section 6. Does your partner drink alcohol: Y N Antenatal Booking Form University Hospitals
NHS Trust
Health in This Pregnancy Current Units______________________________________
Welcome to the Department of Women’s Health.
First day of last period ______________________________ Your Smoking: Never
We look forward to caring for you in your pregnancy.
Current How many per day _______
Are you taking folic acid Y N Given up Date stopped ____________________
If YES date commenced______________________________ Partner Smoking: Y N
Have you attended the Hospital before? Yes / No
Do you require an interpreter? Yes / No If YES Language required__________________________
Vit D Y N Any other information that you think is relevant Do you have any speech, hearing, visual or mobility disability that may affect the delivery of our care?
If YES date commenced______________________________ _________________________________________________
_________________________________________________ Please give details:
Are you currently taking any medication Y N Please complete ALL of this form by ticking the relevant boxes to the best of your abilities
If YES date commenced _____________________________ Is this a multiple pregnancy Y N Unknown
Section 1
Have you taken illicit drugs in the past Y N _______
Have you ever had a smear YES / NO Title_______ Contact Telephone Numbers:
_________________________________________________
Have you had a smear test within the last 3 years YES / NO
Have you taken any substances or illicit drugs in this Always Negative YES / NO Surname ___________________________________ Home _______________________________
pregnancy, if so what ______________________________ Have you ever had a Colposcopy YES / NO First Names ________________________________ Mobile _______________________________
_________________________________________________
Previous Surname ___________________________ Work _______________________________
Your Height ___________ Booking Weight___________
Alcohol Intake: Pre pregnancy units _________________ at booking Date of Birth ________________________________ NHS Number ________________________________
Current Units _______________________
BMI __________________ Address ___________________________________ Trust I.D Number _____________________________
___________________________________ Intended place of delivery RSCH PRH Home
Section 7. Town ___________________________________ Other Please specify______________________________
Social Factors
Have you, your children or your partner ever had a named social worker YES NO if YES, Child Mother Partner
County ______________ Post Code ___________ May we contact you via SMS Text if necessary?
Are you, your children or your partner on the child protection register YES NO if YES, Child Mother Partner Is this your permanent UK address? YES / NO YES / NO
Are your children living with you YES NO
Are you homeless / temp. accommodation YES NO if YES, Child Mother Partner Are you: Married Cohabiting Single Divorced Civil partnership Widowed
Are you a refugee or asylum seeker YES NO if YES, Child Mother Partner
Are you a recent migrant (within last 12 months) YES NO if YES, Child Mother Partner
One or two parent family ________ Your occupation __________________________________________
Are you under 20 years old YES NO if YES, Child Mother Partner Religion ______________________ Country of Birth __________________________________________

Section 8. Your Ethnic Group: This information is defined by the Dept. of Health; based on the 2001 Census and is only used for
FOR COMPLETION BY MIDWIFE/HOSPITAL LMP __________________________ Healthcare Planning Purposes:
Date of booking _____________________ Booked by______Named Midwife________ EDD __________________________ Asian Bangladeshi Black Caribbean White British Other Ethnic Group
Asian Indian Black African White Irish Other Mixed Group
If booking later than 12 weeks, reason why: __________________________________ No. of weeks at Booking __________ Asian Pakistani Black Other White Other Mixed White/Asian
Has a booking taken place elsewhere: _______________________________________ If Yes - which hospital ____________ Asian Other Chinese Mixed White/Black African
Mixed White/Black Caribbean
Consultant appointment required Yes No. If YES, date _____________________ BP ___________________________
Reason for appointment __________________________________________________________________________________ Your GP’s Name and Surgery __________________________________________ Tel. No. ___________________
Model of care: Midwifery Maternity team care Hospital team Partner’s name_____________________________________ Next of Kin __________________________
NHS Private Overseas visitor for the last 12 months Yes / No (Next of Kin if not partner)
Partner’s DOB _____________________________________ Relationship to you __________________
Reason for Were referral
Was referral made? If so to whom? Partner’s Contact No. _______________________________ Contact No. (Home) __________________
Referral questions asked?
Low Intermediate High N/A Baby’s Father’s Ethnic Group ________________________ (Mobile) ____________________________
VTE YES NO
To whom:
Yes Declined N/A BMI Measurement:
BMI YES NO
To whom:
Section 2. Respiratory Disease Y N________________
Yes Declined N/A CO2 Reading: Declined Your Medical History (Severe asthma/TB/Chest Problems)
Smoking YES NO
To whom: Please include details of any current treatment/care Asthma requiring medications Y N________________
Yes Declined N/A
Worth/Rise YES NO Cystic Fibrosis Y N________________
To whom: Are you allergic to anything e.g. Latex, Medications, Food
Yes Declined N/A or other Allergies Y N Back/Limb/Pelvic Y N________________
Whooley YES NO Details:___________________________________________
To whom: Problems
Yes Declined N/A Blood Disorders Y N________________
Teenage YES NO Anaesthetic Reaction Y N________________
To whom: Teenage Midwife Yes No e.g. Thalassaemia or Sickle
Is BCG recommended for Infant ? Autoimmune Disease Y N________________ Cell or Anaemia ____________________________________________
BCG YES NO
Yes No Details Have you ever had a Blood Transfusion? Y N
Skin Conditions Y N________________
(Eczema, psoriasis) Would you accept blood/blood products? Y N

WGN500432 Maternity Department PRH/RSCH 4 Date intro. 16/08/16 WGN500432 Maternity Department PRH/RSCH 1 Date intro. 16/08/16
Antenatal Notes Date approved 08.08.16 Antenatal Notes Date approved 08.08.16
 Section 2 cont. Your Medical History Kidney Disease Y N________________ Section 5. PREVIOUS PREGNANCY DETAILS See medical notes
Cardiac Conditions or Y N________________ Urine Problems Y N________________ This section is to record details of your previous pregnancies, including miscarriages and
Problems/Surgery (Inc cystitis/UTI)
terminations. If this information needs to be treated in confidence please discuss this with the
Cancer Y N________________ Liver Disease Y N________________ midwife as alternative arrangements can be made.
(including Hepatitis/Jaundice)

Birth Present
Diabetes Y N________________

Epilepsy (Folic Acid)
Are you on epileptic drugs
Central Nevous System
Conditions
(Under the care of a neurologist)
Y N________________
Y N________________
Y N________________
Mental Health
(including depression)
Other relevant conditions
or problems
FGM/Circumcision/Cutting
weight health
Y N________________
Y N________________
Y N________________

(If BF give
Feeding
Previous Surgery Y N________________

Genital Infections (Syphilis)
(Group B Strep. in
previous pregnancy)
Hypertension
(High Blood Pressure)
Y N________________
Y N________________
Y N________________
duration)
Previous Organ Transplant Y N________________
Previous Uterine Surgery Y N________________
(including Caesarean)

(first last)
Thrombosis (blood clot) Y N________________

Name
Infertility/Gynae Problems Y N________________ Thyroid/other endocrine Y N________________
Have you had fertility treatment disorders
in this pregnancy, if so what

Outcome
(Misc/ Live
_________________________________________________

SB/ NND)
Gastrointestinal Conditions Y N________________
_________________________________________________ (Crohn’s, colitis, gastric ulcer)

NND

NND

NND

NND

NND
Live

Live

Live

Live

Live
SB

SB

SB

SB

SB

Early Pregnancy Losses

Section 3.
Family History Are you Adopted? Yes No

(include relevant
Type of birth
The following questions only apply to your immediate
family.

Caesarian

Caesarian

Caesarian

Caesarian

Caesarian
The following questions apply to both you and your

Ventouse

Ventouse

Ventouse

Ventouse

Ventouse
Forceps

Forceps

Forceps

Forceps

Forceps
partner’s family. Has any member of your family had:

Breech

Breech

Breech

Breech

Breech
Has any member of your family had:

details)
SVD

SVD

SVD

SVD

SVD
History of learning difficulties Y N
Diabetes Y N Type: Insulin dependent
Diet controlled Congenital disorder Y N
What relation to you _______________ Congenital dislocation of hips Y N

_______________

_______________

_______________

_______________

_______________
History of twins Y N

Labour details:
Complications
Hypertension Y N What relation to you __________ Genetic inherited condition (incl McADD) Y N
(incl. PIH/Eclampsia)
If yes to any please specify _________________________
Sickle Disease Y N What relation to you__________

N
_________________________________________________

Comments
Thalassaemia Y N What relation to you___________ _________________________________________________
Are you and your partner blood relatives? YES / NO

Y
Postnatal Depression Y N

_________

_________

_________

_________

_________
Antenatal
What relation to you________________________________

problems

N
Section 4. Puerperal psychosis Y N

Y
Previous Other Pregnancy Conditions _________________________________________________

Gestation Nature of loss

_________________________________________________

Previous gestational
diabetes
Previous pregnancy
induced hypertension
M/F
Y N________________ _________________________________________________
Sex
Previous requirement for Y N ________________
fetal medicine (please specify)
Place of
Y N________________
Birth

Required specialist input Y N

(including PIH/HELLP/Pre eclampsia/Eclampsia)
Previous pre term birth Y N ________________
Previous fetal congenital Y N ________________ before 34 weeks
Gest

anomaly (please specify)

Previous growth restriction/ Y N ________________
Required specialist input Y N small baby (IUGR)

Previous history of postnatal depression Y N Placental Problems Y N ________________

Date

Year
(including IUGR/Placenta Accreta/ Manual removal of placenta)

WGN500432 Maternity Department PRH/RSCH 2 Date intro. 16/08/16 WGN500432 Maternity Department PRH/RSCH 3 Date intro. 16/08/16
Antenatal Notes Date approved 08.08.16 Antenatal Notes Date approved 08.08.16
 Section 2 cont. Your Medical History Kidney Disease Y N________________ Section 5. PREVIOUS PREGNANCY DETAILS See medical notes
Cardiac Conditions or Y N________________ Urine Problems Y N________________ This section is to record details of your previous pregnancies, including miscarriages and
Problems/Surgery (Inc cystitis/UTI)
terminations. If this information needs to be treated in confidence please discuss this with the
Cancer Y N________________ Liver Disease Y N________________ midwife as alternative arrangements can be made.
(including Hepatitis/Jaundice)

Birth Present
Diabetes Y N________________

Epilepsy (Folic Acid)
Are you on epileptic drugs
Central Nevous System
Conditions
(Under the care of a neurologist)
Y N________________
Y N________________
Y N________________
Mental Health
(including depression)
Other relevant conditions
or problems
FGM/Circumcision/Cutting
weight health
Y N________________
Y N________________
Y N________________

(If BF give
Feeding
Previous Surgery Y N________________

Genital Infections (Syphilis)
(Group B Strep. in
previous pregnancy)
Hypertension
(High Blood Pressure)
Y N________________
Y N________________
Y N________________
duration)
Previous Organ Transplant Y N________________
Previous Uterine Surgery Y N________________
(including Caesarean)

(first last)
Thrombosis (blood clot) Y N________________

Name
Infertility/Gynae Problems Y N________________ Thyroid/other endocrine Y N________________
Have you had fertility treatment disorders
in this pregnancy, if so what

Outcome
(Misc/ Live
_________________________________________________

SB/ NND)
Gastrointestinal Conditions Y N________________
_________________________________________________ (Crohn’s, colitis, gastric ulcer)

NND

NND

NND

NND

NND
Live

Live

Live

Live

Live
SB

SB

SB

SB

SB

Early Pregnancy Losses

Section 3.
Family History Are you Adopted? Yes No

(include relevant
Type of birth
The following questions only apply to your immediate
family.

Caesarian

Caesarian

Caesarian

Caesarian

Caesarian
The following questions apply to both you and your

Ventouse

Ventouse

Ventouse

Ventouse

Ventouse
Forceps

Forceps

Forceps

Forceps

Forceps
partner’s family. Has any member of your family had:

Breech

Breech

Breech

Breech

Breech
Has any member of your family had:

details)
SVD

SVD

SVD

SVD

SVD
History of learning difficulties Y N
Diabetes Y N Type: Insulin dependent
Diet controlled Congenital disorder Y N
What relation to you _______________ Congenital dislocation of hips Y N

_______________

_______________

_______________

_______________

_______________
History of twins Y N

Labour details:
Complications
Hypertension Y N What relation to you __________ Genetic inherited condition (incl McADD) Y N
(incl. PIH/Eclampsia)
If yes to any please specify _________________________
Sickle Disease Y N What relation to you__________

N
_________________________________________________

Comments
Thalassaemia Y N What relation to you___________ _________________________________________________
Are you and your partner blood relatives? YES / NO

Y
Postnatal Depression Y N

_________

_________

_________

_________

_________
Antenatal
What relation to you________________________________

problems

N
Section 4. Puerperal psychosis Y N

Y
Previous Other Pregnancy Conditions _________________________________________________

Gestation Nature of loss

_________________________________________________

Previous gestational
diabetes
Previous pregnancy
induced hypertension
M/F
Y N________________ _________________________________________________
Sex
Previous requirement for Y N ________________
fetal medicine (please specify)
Place of
Y N________________
Birth

Required specialist input Y N

(including PIH/HELLP/Pre eclampsia/Eclampsia)
Previous pre term birth Y N ________________
Previous fetal congenital Y N ________________ before 34 weeks
Gest

anomaly (please specify)

Previous growth restriction/ Y N ________________
Required specialist input Y N small baby (IUGR)

Previous history of postnatal depression Y N Placental Problems Y N ________________

Date

Year
(including IUGR/Placenta Accreta/ Manual removal of placenta)

WGN500432 Maternity Department PRH/RSCH 2 Date intro. 16/08/16 WGN500432 Maternity Department PRH/RSCH 3 Date intro. 16/08/16
Antenatal Notes Date approved 08.08.16 Antenatal Notes Date approved 08.08.16
 WGN500432
Brighton and Sussex
Section 6. Does your partner drink alcohol: Y N Antenatal Booking Form University Hospitals
NHS Trust
Health in This Pregnancy Current Units______________________________________
Welcome to the Department of Women’s Health.
First day of last period ______________________________ Your Smoking: Never
We look forward to caring for you in your pregnancy.
Current How many per day _______
Are you taking folic acid Y N Given up Date stopped ____________________
If YES date commenced______________________________ Partner Smoking: Y N
Have you attended the Hospital before? Yes / No
Do you require an interpreter? Yes / No If YES Language required__________________________
Vit D Y N Any other information that you think is relevant Do you have any speech, hearing, visual or mobility disability that may affect the delivery of our care?
If YES date commenced______________________________ _________________________________________________
_________________________________________________ Please give details:
Are you currently taking any medication Y N Please complete ALL of this form by ticking the relevant boxes to the best of your abilities
If YES date commenced _____________________________ Is this a multiple pregnancy Y N Unknown
Section 1
Have you taken illicit drugs in the past Y N _______
Have you ever had a smear YES / NO Title_______ Contact Telephone Numbers:
_________________________________________________
Have you had a smear test within the last 3 years YES / NO
Have you taken any substances or illicit drugs in this Always Negative YES / NO Surname ___________________________________ Home _______________________________
pregnancy, if so what ______________________________ Have you ever had a Colposcopy YES / NO First Names ________________________________ Mobile _______________________________
_________________________________________________
Previous Surname ___________________________ Work _______________________________
Your Height ___________ Booking Weight___________
Alcohol Intake: Pre pregnancy units _________________ at booking Date of Birth ________________________________ NHS Number ________________________________
Current Units _______________________
BMI __________________ Address ___________________________________ Trust I.D Number _____________________________
___________________________________ Intended place of delivery RSCH PRH Home
Section 7. Town ___________________________________ Other Please specify______________________________
Social Factors
Have you, your children or your partner ever had a named social worker YES NO if YES, Child Mother Partner
County ______________ Post Code ___________ May we contact you via SMS Text if necessary?
Are you, your children or your partner on the child protection register YES NO if YES, Child Mother Partner Is this your permanent UK address? YES / NO YES / NO
Are your children living with you YES NO
Are you homeless / temp. accommodation YES NO if YES, Child Mother Partner Are you: Married Cohabiting Single Divorced Civil partnership Widowed
Are you a refugee or asylum seeker YES NO if YES, Child Mother Partner
Are you a recent migrant (within last 12 months) YES NO if YES, Child Mother Partner
One or two parent family ________ Your occupation __________________________________________
Are you under 20 years old YES NO if YES, Child Mother Partner Religion ______________________ Country of Birth __________________________________________

Section 8. Your Ethnic Group: This information is defined by the Dept. of Health; based on the 2001 Census and is only used for
FOR COMPLETION BY MIDWIFE/HOSPITAL LMP __________________________ Healthcare Planning Purposes:
Date of booking _____________________ Booked by______Named Midwife________ EDD __________________________ Asian Bangladeshi Black Caribbean White British Other Ethnic Group
Asian Indian Black African White Irish Other Mixed Group
If booking later than 12 weeks, reason why: __________________________________ No. of weeks at Booking __________ Asian Pakistani Black Other White Other Mixed White/Asian
Has a booking taken place elsewhere: _______________________________________ If Yes - which hospital ____________ Asian Other Chinese Mixed White/Black African
Mixed White/Black Caribbean
Consultant appointment required Yes No. If YES, date _____________________ BP ___________________________
Reason for appointment __________________________________________________________________________________ Your GP’s Name and Surgery __________________________________________ Tel. No. ___________________
Model of care: Midwifery Maternity team care Hospital team Partner’s name_____________________________________ Next of Kin __________________________
NHS Private Overseas visitor for the last 12 months Yes / No (Next of Kin if not partner)
Partner’s DOB _____________________________________ Relationship to you __________________
Reason for Were referral
Was referral made? If so to whom? Partner’s Contact No. _______________________________ Contact No. (Home) __________________
Referral questions asked?
Low Intermediate High N/A Baby’s Father’s Ethnic Group ________________________ (Mobile) ____________________________
VTE YES NO
To whom:
Yes Declined N/A BMI Measurement:
BMI YES NO
To whom:
Section 2. Respiratory Disease Y N________________
Yes Declined N/A CO2 Reading: Declined Your Medical History (Severe asthma/TB/Chest Problems)
Smoking YES NO
To whom: Please include details of any current treatment/care Asthma requiring medications Y N________________
Yes Declined N/A
Worth/Rise YES NO Cystic Fibrosis Y N________________
To whom: Are you allergic to anything e.g. Latex, Medications, Food
Yes Declined N/A or other Allergies Y N Back/Limb/Pelvic Y N________________
Whooley YES NO Details:___________________________________________
To whom: Problems
Yes Declined N/A Blood Disorders Y N________________
Teenage YES NO Anaesthetic Reaction Y N________________
To whom: Teenage Midwife Yes No e.g. Thalassaemia or Sickle
Is BCG recommended for Infant ? Autoimmune Disease Y N________________ Cell or Anaemia ____________________________________________
BCG YES NO
Yes No Details Have you ever had a Blood Transfusion? Y N
Skin Conditions Y N________________
(Eczema, psoriasis) Would you accept blood/blood products? Y N

WGN500432 Maternity Department PRH/RSCH 4 Date intro. 16/08/16 WGN500432 Maternity Department PRH/RSCH 1 Date intro. 16/08/16
Antenatal Notes Date approved 08.08.16 Antenatal Notes Date approved 08.08.16