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!!! 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. If you need help completing this form, please call 020 3315 6000 (Chelsea) or 020 8321 5839 (West Middlesex). Please note: If you have not heard from us within 10 business days, please call us on the numbers above. Personal details First name Surname/family name How would you like to be known If you prefer to called by a different name, let us know Title Mrs Miss Ms Mr Dr Prof Other Prefer not to say Date of birth How would you describe your gender? (if you wish to tell us) Is your gender the same as your sex assigned at birth? yes no (if you wish to tell us) What are your pronouns? She/her He/him They/them (if you wish to tell us) How would you describe your sexual orientation? (if you wish to tell us) What is your 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 a language interpreter or BSL 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? If you require a BSL interpreter, enter BSL here Do you read and write English? yes no Mobile telephone number Do you give us permission to be contacted by text message? yes no Alternative telephone number Email address Can we email you at this address? yes no Hospital number (if known) NHS number (if known) 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 first appointment Let us know if you have any additional needs that will support your care (for example, learning difficulties, disabilities, autism) Where have you lived in the last 12 months? Within the UK Outside the UK Are you a UK resident? yes no See this link to understand why we ask this www.birthrights.org.uk/wp-content/uploads/2021/08/NHS-charging-FINAL.pdf Are you a refugee or asylum seeker? yes no Are you a member of the armed forces community? yes no Your address Street address 1 Street address 2 Town County Postcode Next of kin Emergency contact number Name of kin Their relationship to you 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) Is this an IVF pregnancy? yes no If yes, what was the date of the embryo transfer? Approximately how many weeks pregnant are you? If you have had antenatal care elsewhere for this pregnancy, please provide details (name of hospital and country) Are you interested in finding out more about a homebirth? Yes No Is this the first time you have been pregnant? yes no If yes, go to the next section (medical history) Number of vaginal births Including ventouse, kiwi cup and forceps births (if this is not your first pregnancy) Number of Caesarean births (if this is not your first pregnancy) Have you given birth to a live baby before 37 weeks (preterm)? yes no (if this is not your first pregnancy) If yes, how many weeks were you when your baby was born? (if this is not your first pregnancy) If you’ve ever had a termination of pregnancy, please give details We understand this question may be difficult for you but your answer will help us plan the best care for your pregnancy If you’ve ever lost (miscarried) a baby before 12 weeks gestation, please give details We understand this question may be difficult for you but your answer will help us plan the best care for your pregnancy If you’ve ever had any babies that were stillborn, please give details We understand this question may be difficult for you but your answer will help us plan the best care for your pregnancy If you’ve had any babies born alive who have since died, please give details We understand this question may be difficult for you but your answer will help us plan the best care for your pregnancy Details of any babies diagnosed with a medical or genetic condition before or after birth (if this is not your first pregnancy) Did you have any medical problems in a previous pregnancy, during labour or after your baby was born? (for example, assisted fertility, pre-eclampsia, obstetric cholestasis (itching), high blood pressure, gestational diabetes, severe bleeding etc—please give as much detail as you can) Medical history Medical conditions Cardiac (heart) condition High blood pressure Stomach, bowel or liver condition—eg IBD, Crohn’s etc Blood (haematology) condition—eg sickle cell, thalassaemia (incl carrier), blood clots etc Endocrine condition—eg Type 1/2 diabetes, thyroid disease etc Renal (kidney) condition—eg recurrent UTIs etc Neurological (brain) condition—eg epilepsy, stroke, MS etc Respiratory (breathing) condition—eg asthma etc Autoimmune condition—eg lupus, arthritis etc HIV Skin condition—eg eczema, psoriasis etc Cancer I am a smoker I am a vaper Someone in my house smokes/vapes None of these (please tick all that apply) If you ticked any of the above, please provide brief details Please provide any details of long term mental health or wellbeing conditions For example, depression, anxiety, eating disorders etc—please include any medications you take to manage these Tell us about any other health conditions you think we need to know about Please list all medications and the dosages you are taking for any medical and mental health conditions, including vitamins The NHS recommends a daily dose (400mcg) of folic acid in pregnancy. Some people may need a higher dose. Find out more at www.nhs.uk/pregnancy/keeping-well/vitamins-supplements-and-nutrition/ Social complexities Please tick all that apply Social worker Safeguarding concerns (domestic violence) Alcohol use concerns Substance use concerns (recreational drug use) None of these We understand that this question is sensitive. Please answer honestly so that we can arrange the most appropriate support for you and your family. If you ticked any of the above, please provide brief details. If you or any of your children have a social worker, please let us know their name and telephone number. Is there anything else you think we should know about to support you during pregnancy, birth or after your baby is born? Submit Contributors George Vasilopoulos admin
