Self-refer online https://www.chelwest.nhs.uk/services/maternity/self-refer-online https://www.chelwest.nhs.uk/++resource++plone-logo.svg Self-refer online User email: Please leave this blank!!! Welcome to Chelsea and West Middlesex and congratulations on your pregnancy. Please answer all the questions below as best you can so that we may support you appropriately. If you require the questions to be translated, please use the ‘Recite’ function above and let us know if you will need translation support for your appointments. Arabic: مرحبا بكم في تشيلسي وويست ميدلسكس وتهانينا على حملك. يرجى الإجابة على جميع الأسئلة أدناه بأفضل ما يمكنك حتى نتمكن من دعمك بشكل مناسب. إذا كنت بحاجة إلى ترجمة الأسئلة ، فيرجى استخدام وظيفة "التلاوة" أعلاه وإخبارنا إذا كنت ستحتاج إلى دعم الترجمة لمواعيدك. Hindi: चेल्सी और वेस्ट मिडलसेक्स में आपका स्वागत है और आपकी गर्भावस्था के लिए बधाई। कृपया नीचे दिए गए सभी प्रश्नों का सर्वोत्तम उत्तर दें ताकि हमआपको उचित रूप से समर्थन दे सकें। यदि आपको प्रश्नों का अनुवाद करने की आवश्यकता है, तो कृपया ऊपर दिए गए 'पाठ करें' फ़ंक्शन का उपयोगकरें और हमें बताएं कि क्या आपको अपनी नियुक्तियों के लिए अनुवाद समर्थन की आवश्यकता होगी। Punjabi: ਚੇਲਸੀ ਅਤੇ ਵੈਸਟ ਮਿਡਲਸੈਕਸ ਵਿੱਚ ਤੁਹਾਡਾ ਸਵਾਗਤ ਹੈ ਅਤੇ ਤੁਹਾਡੀ ਗਰਭਅਵਸਥਾ ਲਈ ਵਧਾਈਆਂ। ਕਿਰਪਾ ਕਰਕੇ ਹੇਠਾਂ ਦਿੱਤੇ ਸਾਰੇ ਸਵਾਲਾਂ ਦੇ ਜਵਾਬ ਦਿਓ ਜਿੰਨਾ ਵਧੀਆ ਹੋਸਕੇ ਤਾਂ ਜੋ ਅਸੀਂ ਤੁਹਾਡੀ ਉਚਿਤ ਸਹਾਇਤਾ ਕਰ ਸਕੀਏ। ਜੇ ਤੁਹਾਨੂੰ ਸਵਾਲਾਂ ਦਾ ਅਨੁਵਾਦ ਕਰਨ ਦੀ ਲੋੜ ਹੈ, ਤਾਂ ਕਿਰਪਾ ਕਰਕੇ ਉੱਪਰ ਦਿੱਤੇ 'ਪਾਠ' ਫੰਕਸ਼ਨ ਦੀ ਵਰਤੋਂ ਕਰੋ ਅਤੇ ਸਾਨੂੰਦੱਸੋ ਕਿ ਕੀ ਤੁਹਾਨੂੰ ਆਪਣੀਆਂ ਮੁਲਾਕਾਤਾਂ ਵਾਸਤੇ ਅਨੁਵਾਦ ਸਹਾਇਤਾ ਦੀ ਲੋੜ ਪਵੇਗੀ। Somali: Kusoo dhawoow Chelsea & West Middlesex iyo hambalyo ku saabsan uurkaaga. Fadlan uga jawaab dhamaan suʼaalahan hoose sida ugu wanaagsan ee aad awoodi kartid si aan kuugu taageerno si ku haboon. Haddii aad u baahantahay su'aalaha lagu turjumi karo, fadlan adeegso shaqada 'Akhriso' ee kor ku xusan noo soo sheeg haddii aad u baahantahay taageero turjumaad ah si aad ballantaada u heshid. Urdu: چیلسی اور ویسٹ مڈل سیکس میں خوش آمدید اور آپ کے حمل پر مبارک ہو. برائے مہربانی ذیل میں دیئے گئے تمام سوالات کا بہترین جواب دیں تاکہ ہم آپ کی مناسب مدد کرسکیں۔ اگر آپ سوالات کا ترجمہ کرنا چاہتے ہیں تو، براہ کرم اوپر دیئے گئے 'تلاوت' فنکشن کا استعمال کریں اور ہمیں بتائیں کہ آیا آپ کو اپنی ملاقاتوں کے لئے ترجمہ کی مدد کی ضرورت ہوگی. Please complete all relevant details as soon as possible following your positive pregnancy test so we can book you in for your first appointment in a timely manner. Any missing information may slow this process. You will normally be seen for your first appointment at 8–10 weeks, depending on your gestation when we receive your self-referral. To help you make choices about your care, please read the following useful information: My Health London maternity information Which? Birth Choice Our Mum and Baby app: Mum & Baby app Our Mum & Baby app supports your journey with us through your pregnancy, birth and life with your baby—download it today! Please note: If you have not heard from us within 10 business days, please call the helpline number to look into your self-referral—Chelsea site 020 3315 6000 or West Middlesex site 020 8321 5839. Personal details First name Surname Date of birth Maiden name (if applicable) Marital status single married civil partnered divorced widowed Preferred contact number Can we send text/sms messages to this number to notify you of appointments? yes no Email address Can we email you at this address? yes no Hospital number (if known) NHS number (if known) Ethnicity Asian/Asian British - Bangladeshi Asian/Asian British - Indian Asian/Asian British - Pakistani Asian - any other Asian background Black/Black British - African Black/Black British - Caribbean Black - any other Black background Mixed - White and Asian Mixed - White and Black African Mixed - White and Black Caribbean Mixed - any other mixed background White - British White - Irish White - any other White background Other - Chinese Other - any other ethnic group Your ethnicity describes your cultural or ancestral heritage, which is inherited from your ancestors, your parents or grandparents. This may be different to your nationality, which is your legal identity, the country where you are a legal citizen. You may have been born in this country, or you may have moved here and became a citizen. Knowing your correct ethnicity is important to us as it helps us provide the best possible maternity care for you as an individual. Pregnant people from certain ethnic backgrounds can be more at risk of some pregnancy complications. Do you require an interpreter? yes no Our Trust policy excludes the use of friends or relatives as interpreters. If we do not know about your interpreter requirements in advance, we may need to reschedule your appointment. If yes, which language do you speak? At which site would you like to have your care? Chelsea and Westminster Hospital West Middlesex University Hospital You can choose to have the majority of your care at either Chelsea and Westminster Hospital or West Middlesex University Hospital. Please note that in some cases some of your care may need to take place at the other site—this will be discussed with you if necessary. Let us know any dates you cannot attend your booking appointment Let us know the details of any disability we need to be aware of when arranging your appointment Where have you lived in the last 12 months? Within the UK Outside the UK (please bring your passport or any other documentation you have to support your residency in the UK) Your address Street address 1 Street address 2 Town County Postcode Next of kin Name of next of kin Relationship to you Contact number GP details GP/practice name Street address 1 Street address 2 Town County Postcode Contact number Current pregnancy First day of your last period (if unsure, please leave blank and answer the next question) Approximately how many weeks pregnant are you? Are you interested in finding out more about a homebirth? Yes No If you have had antenatal care elsewhere for this pregnancy, please provide details (name of hospital and country) Total number of pregnancies (including miscarriages or terminations) Number of vaginal births Number of ventouse/forceps births Number of Caesarean sections Number of pre-term births (before 37 weeks) Details of any babies diagnosed with a medical condition before or after birth Any other details (for example assisted fertility, pre-eclampsia, obstetric cholestasis, gestational diabetes etc) Medical history Medical and mental health history Cardiac (heart) condition High blood pressure Sickle cell/thalassaemia (or carry the trait) Diabetes Renal (kidney) disease Liver disease Haematology (blood) condition Thyroid disease Neurological (brain) condition Respiratory condition (eg asthma) Cancer treatment I am a smoker Someone in my house smokes Mental health problem (eg depression, anxiety, eating disorder etc) None of these (please tick all that apply) If you ticked any of the above, please provide brief details including any medication taken Social complexities Please tick all that apply Learning difficulties Social worker Safeguarding concerns Alcohol use concerns Domestic abuse concerns Substance use concerns None of these If you ticked any of the above, please provide brief details Vaccination Have you been vaccinated for COVID-19? Yes - 1 dose Yes - 2 doses Yes - 2 doses + booster No Studies have shown that hospital admission and severe illness are more common in pregnant women (compared to those not pregnant). If you decide to have a COVID-19 vaccine, please see our vaccination in pregnancy page (a link is provided after you've completed this form). Submit Contributors George Vasilopoulos admin
