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!!! This form will be used to help us understand more about you so we can provide safe, personalised care throughout your pregnancy. Some questions may feel personal. These help us provide the best possible care during your pregnancy. You will have a chance to speak privately with a midwife at your first appointment. Your answers will be added to your confidential medical records and will only be seen by staff involved in your care. Sharing as much as you can helps us plan care for you and your baby. Please note: Throughout this form, “you” and “your” refer to the woman or birthing person who is currently pregnant. Personal details Are you completing this form for: yourself (I am pregnant) someone else (I am completing this for a pregnant person) If you selected “someone else”, please tell us your relationship to the woman/birthing person If you are completing this form for someone else, enter the pregnant person’s details in the questions below. First name First name of the pregnant person Surname/family name Surname of the pregnant person Please list any previous names you have used If none, write “none” What are your pronouns? She/her/hers He/him/his They/them/theirs Other Prefer not to say If other, what pronoun(s) should we use? Date of birth Home address (line 1) Home address (line 2) Optional Town or city County Optional Postcode Mobile phone number If you do not have a mobile phone, please provide another number where we can reach you Email address NHS number If you know your NHS number, please include it. If not, you can leave this blank. You can find your NHS number at https://www.nhs.uk/nhs-services/online-services/find-nhs-number/ I do not have an NHS number Are you a member of the armed forces community? yes no Are you registered with a GP practice (family doctor)? yes no If yes, please provide the name and address of your GP practice Which hospital would you prefer for your care? Chelsea and Westminster Hospital West Middlesex University Hospital Are you interested in having a home birth? yes no maybe Have you received care for this pregnancy from a doctor or midwife at another hospital or in another country? yes no If yes, please tell us where you received care for this pregnancy For example, the name of the hospital or clinic and the country What is your ethnicity? We ask about your ethnicity during pregnancy because some health conditions and pregnancy risks can affect ethnic groups differently. 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 If other, what is your ethnic group? Do you need an interpreter or British Sign Language (BSL) support? yes no We want to make sure we can communicate with you clearly. Friends and family members cannot act as interpreters. If needed, we can provide an interpreter or BSL support at no cost to you. If yes, what language do you require? (If you require BSL support, enter “BSL”) Is there anything we can do to help you take part in your appointment? This could include how you prefer to communicate, any cultural or religious considerations, support for learning disabilities or neurodiversity, help with physical or sensory disabilities, or any other adjustments you may need. Current pregnancy What was the first day of your last menstrual period? If unsure, please leave blank How many weeks pregnant do you think you are? For example, 12 weeks What is your estimated due date (when your baby is due)? If unsure, please leave blank Is this your first pregnancy? yes no Which of the following applies to you regarding this pregnancy or previous pregnancies? Baby born prematurely (before 37 weeks) Caesarean birth Ectopic pregnancy Fetal anomaly (eg a chromosomal condition such as trisomy) IVF Multiple miscarriages Multiple babies (ie twins, triplets or more) Neonatal death Stillbirth None of these Other Select all that apply. If none apply, select “None of these” only. This question may be difficult for you, but your response will help us identify the most appropriate team to support you throughout your pregnancy. If you have ticked any of the above, including “other”, please provide further details. For example, how many weeks pregnant you were and when it occurred, what treatment you received, what was the date of embryo transfer? Have you had any procedures on your cervix (neck of the womb)? yes no I don't know Is there anything else you would like to tell us about this pregnancy or any previous pregnancies? Medical history Do you have, or have you previously had, any of the following health problems? Antithrombin deficiency Any pregnancy conditions (eg pre-eclampsia, high blood pressure in pregnancy, gestational diabetes) Bone and joint conditions (e.g. rheumatoid arthritis) Blood clot in legs or lungs Blood conditions Bowel conditions Brain conditions (eg epilepsy, stroke, aneurysm) Cancer Deep vein thrombosis (DVT) Genetic conditions (eg sickle cell disease, thalassaemia) Heart conditions Hormone imbalance conditions (eg any type of diabetes, thyroid problems etc) Hyperemesis (very severe sickness in pregnancy—you may be unable to drink, keep fluids down, or stand without feeling faint) Immune system conditions (eg HIV, lupus, MS etc) Kidney conditions Liver conditions (eg any hepatitis) Lung conditions Pulmonary embolism (PE) Sexual health conditions (eg syphilis, gonorrhoea, chlamydia etc) None of these Other Select all that apply. If none apply, select ‘None of these’. Please provide any additional details about your medical condition(s). For example, diagnosis dates, treatment, admission to an intensive care unit or anything else you feel is important for your care. Please list any prescribed medications you are currently taking, or any that you have recently stopped taking since finding out you are pregnant (including the dose if known). This includes blood-thinning medicines such as warfarin, apixaban, rivaroxaban, dabigatran or edoxaban. Do you currently smoke, vape or use e-cigarettes? yes, I smoke yes, I vape yes, I use e-cigarettes no Select all that apply. If you do not smoke or vape, select “no” only. Are you currently drinking alcohol or using any recreational drugs? yes no What is your weight? Weight unit kg (eg 60kg) lb (eg 140lb) st (eg 9st 10lb) What is your height? Height unit cm (eg 170cm) ft/in (eg 5ft 3in) Mental and emotional wellbeing Have you ever been diagnosed with a mental and/or emotional health condition? yes no If yes, please provide any details about your mental health condition(s). For example, diagnoses dates, treatment, medication or anything else you feel is important for your care. Any additional information Is there anything else you would like us to know at this stage? Your feedback Please tell us about your experience with the antenatal self-referral process. Your thoughts help us improve and make things better for others. It was easy to find the form online Agree Neutral Disagree I was able to complete the self-referral without difficulty Agree Neutral Disagree I would recommend this self-referral process to others Agree Neutral Disagree Do you have any suggestions for improving the self-referral process? Submit Contributors George Vasilopoulos admin
