Early Pregnancy Unit questionnaire https://www.chelwest.nhs.uk/services/maternity/self-refer-online/epu-questionnaire https://www.chelwest.nhs.uk/++resource++plone-logo.svg Early Pregnancy Unit questionnaire User email: Please leave this blank!!! 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 and results? yes no Email address Can we email you at this address? yes no This will be discreet and from a secure nhs.net email address GP details GP/practice name Street address 1 Street address 2 Town County Postcode Contact number Permission to contact your GP Yes I consent for the EPU to contact my GP No I do not consent for the EPU to contact my 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) Research and learning Consent to use images Yes I consent for the EPU to carry out my examination No I do not consent for the EPU to carry out my examination 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 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) 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? Yes - 1 dose Yes - 2 doses Yes - 2 doses and 1 booster Yes - 2 doses and 2 boosters 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 inform one of our staff or contact your GP to organise. 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 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 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 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 (please tick all that apply) If you ticked BMI over 30 above, please state your BMI Day Assessment Unit assessment I have the following medical conditions: 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 (please tick all that apply) Enhanced pathway assessment I have the following medical conditions: 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 (please tick all that apply) Social complexities I have the following social complexities: Learning difficulties Social worker Safeguarding concerns Alcohol use concerns Domestic abuse concerns Substance use concerns None of these (please tick all that apply) If you ticked any of the above, please provide brief details Preferences Your scan I understand 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 Email Text message (SMS) Telephone Post Submit Contributors George Vasilopoulos
