Early Pregnancy Unit questionnaire

Personal details
Date of birth  
/ /  
Marital status  

GP details
Research and learning
Reason for your appointment
I have had:  
Current pregnancy
First day of your last period (if unsure, please leave blank and answer the next question)
/ /  
Is this a planned pregnancy?  

Medical history
Have you been vaccinated for COVID-19?   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 inform one of our staff or contact your GP to organise.

Medical and mental health history   (please tick all that apply)
Are you allergic to latex?  

Other medical details   (please tick all that apply)
Day Assessment Unit assessment
I have the following medical conditions:   (please tick all that apply)
Enhanced pathway assessment
I have the following medical conditions:   (please tick all that apply)
Social complexities
I have the following social complexities:   (please tick all that apply)
Your scan   The majority of scans we do in our units are done ‘transvaginally’ which means the ultrasound probe is placed into the lower part of the vagina for improved pelvic assessment. It is not harmful to a pregnancy. It is also safe for you and should not be painful. If you feel unable to complete the scan this way or would like a chaperone during the scan, please let us know on the day.
My preferred method(s) of contact

Contact us


Chelsea and Westminster
T: 020 3315 6000

West Middlesex
T: 020 8321 5608

Mum and Baby app

Our Mum and Baby app supports your journey with us through your pregnancy, birth and life with your baby.

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