Early Pregnancy Unit questionnaire

Personal details

First name  

Surname  

Date of birth  

Year -- 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 / Month -- January February March April May June July August September October November December / Day -- 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31  

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 and results?  

yes
no

Email address  

Can we email you at this address?   This will be discreet and from a secure nhs.net email address

yes
no

GP details

GP/practice name  

Street address 1

Street address 2

Town

County

Postcode

Contact number

Permission to contact your GP   We routinely send letters to your GP regarding your appointments in the Early Pregnancy Unit with your consent (please ensure your GP details above are correct)

Yes I consent for the EPU to contact my GP
No I do not consent for the EPU to contact my GP

Research and learning

Consent to use images   By consenting to your examination in the Early Pregnancy Unit you are also consenting to your scan images and videos to be used for educational and research purposes with any identifying information removed, in accordance to General Medical Council guidance

Yes I consent for the EPU to carry out my examination
No I do not consent for the EPU to carry out my examination

Reason for your appointment

I have had:  

Pain

Bleeding

Vomiting

Previous ectopic pregnancy

Previous molar pregnancy

Other (please specify)

Other

Current pregnancy

First day of your last period (if unsure, please leave blank and answer the next question)

Year -- 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 / Month -- January February March April May June July August September October November December / Day -- 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31  

Approximately how many weeks pregnant are you?

Is this a planned pregnancy?  

Yes
No

Total number of pregnancies   (including this pregnancy, and any previous miscarriages or terminations)

Number of vaginal births   (including ventouse/forceps)

Number of Caesarean sections  

Number of pre-term births   (before 37 weeks)

Number of stillborn children  

Number of miscarriages  

Number of pregnancy terminations  

Number of ectopic or tubal pregnancies  

Any other details (for example assisted fertility, hyperemesis etc)

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.

Yes - 1 dose
Yes - 2 doses
Yes - 2 doses and 1 booster
Yes - 2 doses and 2 boosters
No

Medical and mental health history   (please tick all that apply)

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

Mental health problem (eg depression, anxiety, eating disorder etc)

None of these

If you ticked any of the above, please provide brief details including any medication taken

Details of any previous operations   If you have not had any previous operations, please state 'none'

Details of any problems in previous pregnancies   If you have not had any problems in previous pregnancies, please state 'none'

Details of any allergies   If you do not have any allergies, please state 'none'

Are you allergic to latex?  

Yes
No

Other medical details   (please tick all that apply)

I take injections for thromboprophylaxis/blood thinning

I have previously had a DVT, PE or another clot

My brother/sister or parent has had a thrombosis (clot)

I am a smoker

My age is 35 or above

I have had 3 or more children

I have varicose veins

My BMI is 30 or greater

This pregnancy is IVF

None of these

If you ticked BMI over 30 above, please state your BMI

Day Assessment Unit assessment

I have the following medical conditions:   (please tick all that apply)

Current or previous clots in my veins or lungs

Heart problems such as pulmonary hypertension, mitral stenosis, artificial heart valve etc

Previous heart failure

Epilepsy or fits while pregnant

Cystic fibrosis

Organ transplant or on renal dialysis

Taking Warfarin, Methotrexate or Prednisolone

None of these

Enhanced pathway assessment

I have the following medical conditions:   (please tick all that apply)

Diabetes

Hyperthyroidism or high thyroid hormones

Antipsychotic medication for mental health problems

Active bowel disease, such as Crohn’s, ulcerative colitis, coeliac disease etc

Epilepsy or fits but no fits while pregnant

Systemic lupus erythematosus (SLE) or rheumatoid arthritis

Previous heart attack or stroke

On medication for high blood pressure

HIV or Hepatitis B/C positive

Haemophilia

Sickle cell disease or beta thalassaemia disease

My baby may need early specific invasive tests

Previous second trimester (between 3 and 7 months) pregnancy loss

Previous delivery before 8 months

Two or more operations on my cervix (LLETZ or cone biopsy)

None of these

Social complexities

I have the following 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

Preferences

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.

I understand

My preferred method(s) of contact

Email

Text message (SMS)

Telephone

Post